HEDIS RN

Actively looking to hire multiple RNs that are looking for a HEDIS role. This role is starting in November - must have at least 3 seasons of HEDIS completed as well as an active RN license. LPNs are not being considered at this time.

• Review clinical data and documentation to determine claim payment decisions based on internal policies and National Committee for Quality Assurance (NCQA) guidelines.

• Evaluate denied claims to determine whether to overturn or uphold the denial, and submit complex or unclear cases to the Medical Director for further review.

• Prepare comprehensive case reviews for the Medical Director when medical necessity criteria are not met based on the available clinical information.

• Generate clear and accurate appeal resolution communications to members and providers in accordance with company policies and NCQA guidelines.

• Create system authorization events for decisions where previously denied claims are overturned.

• Request additional clinical information from providers, as appropriate, to facilitate timely and thorough appeals resolution.

• Gather, organize, and prepare case information and documentation for Administrative Law Hearings.

• Maintain the appeals process within prescribed NCQA time frames, ensuring compliance with turnaround requirements and accurate tracking in the appeals database.

• Assist the Medical Director in revising, updating, and creating new policies and procedures to satisfy NCQA standards and contractual requirements.

• Apply nursing knowledge, including familiarity with HEDIS measures and medical guidelines, to support accurate and consistent utilization and appeals review.

• Active RN license.

• Nursing background with exposure to HEDIS and medical quality measures.

• 3+ seasons of recent HEDIS experience

• Comfortable working with electronic systems and databases to track appeals and authorization events.

This position operates in a professional clinical and administrative setting focused on medical necessity and appeals review. Work is primarily computer-based, using Microsoft Office and internal systems to review clinical documentation, track appeals, and generate communications. The role requires adherence to NCQA time frames, regulatory standards, and contractual requirements, with a strong emphasis on accuracy, timeliness, and collaboration with Medical Directors and other clinical staff.

Standard business attire is expected in office or hearing settings, and the environment supports detailed, focused work on complex medical and regulatory cases.

This is a Contract position based out of Tampa, FL.

The pay range for this position is $38.00 - $42.00/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)

This is a Contract position based out of Tampa, FL.

This position is anticipated to…