Medical Reviewer Analyst

Overview

Provides ongoing HEDIS/QARR/Risk Adjustment medical record collection and abstraction, as well as the collection of records related to Quality Management and Risk Adjustment initiatives. Responsible for clinical audits needed across products. Provides accurate assessment of provider performance against HEDIS/QARR standards and procedures. Adheres to HIPAA confidentiality requirements for protected health information. Works under general supervision.

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 20 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer‑matched retirement saving funds
• Personal and financial wellness programs
• Pre‑tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

• Interacts directly with provider offices, clinics, and other healthcare facilities on the retrieval of medical records for review and abstraction pertaining to HEDIS/QARR/Risk Adjustment and other focused audits/studies. Provides guidance on protocol as required.
• Schedules and performs onsite medical record reviews with high volume providers for compliance with HEDIS/QARR/Risk Adjustment standards.
• Manages and organizes scanned medical records in a central repository inclusive of performing data entry, scanning relevant components of the medical record to support reviews performed, and using appropriate naming convention.
• Safeguards confidentiality of the medical charts/records and complies with all local, state, and federal laws pertaining to medical records. Assures compliance with all HIPAA regulations concerning use, retrieval, storage, and sharing of medical records.
• Educates providers and office staff on HEDIS/QARR quality metrics, Risk Adjustment specifications, and medical record review criteria.
• Participates in required trainings. Participates and assist in quality improvement audits, Risk Adjustment Data Validation (RADV) and other Risk Adjustment surveys and focused studies.
• Maintains a comprehensive understanding of the QM and Risk Adjustment (RA) policies and procedures and ensure compliance.
• Accesses scanned copies of medical records in appointed vendor tool or from Client’s VPN directory.
• Follows up on all outstanding issues found during medical record review. This includes initiation and completion of chart issues.
• Accesses EMR's to get pertinent information.
• Quality Management Only:
• Evaluates documentation discrepancies identified during initial review and advises on corrective actions as appropriate. Reviews and enters documentation findings into a database.
• Abstracts medical data from medical records assigned to consultant in a precise and proficient manner.
• Abstracts data, annotate medical records and enter information into the appointed vendor data collection tool per HEDIS® MY 2024 specifications.
• Provides accurate assessment of provider performance against HEDIS/QARR standards and procedures. Responsible for clinical audits needed across products.
• Risk Adjustment Only:
• Assists with getting provider attestations for Medical Records with signature impairment for any government audit.
• Participates in special projects and performs other duties as assigned.

• Associate's Degree in Nursing, Health Care Administration, Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coder, Allied Health professional or other health related field required

• Minimum two year experience in medical record retrieval and review required or
• Quality Management Only:
• Minimum of one year quality improvement experience in Medicare, Medicaid or Commercial Health Plan Knowledge of HEDIS/QARR standards, medical terminology, strong computer and organizational skills required
• Ability to evaluate medical records with attention to detail required
• Ability to use databases and prepare…