HEDIS Utilization Review Nurse

Title:

HEDIS Utilization Review Nurse

Reports to:

Director of Managed Care

FLSA Status:
Exempt

Personnel Supervised:
None

POSITION SUMMARY:

The HEDIS Utilization Review Specialist is responsible for performing comprehensive reviews of medical records to collect data required for HEDIS reporting. This role supports quality improvement initiatives by identifying gaps in care, validating clinical documentation, and ensuring compliance with NCQA (National Committee for Quality Assurance) standards.

KEY RESPONSIBILITIES:

* Review medical records and clinical data for HEDIS-specific measures.

* Abstract and input accurate clinical data from electronic health records (EHRs) into reporting tools.

* Identify and report documentation deficiencies or care gaps.

* Collaborate with providers, coders, and clinical teams to ensure proper documentation and follow-up.

* Assist in the coordination and execution of the annual HEDIS data collection cycle.

* Maintain knowledge of current HEDIS specifications and regulatory updates.

* Support audits and internal quality improvement initiatives related to clinical outcomes.

* Ensure HIPAA compliance and confidentiality of patient information.

SKILLS:

* Strong knowledge of HEDIS measures and NCQA guidelines.

* Proficient in EHR systems and chart review processes.

* Detail-oriented with strong analytical and organizational skills.

* Excellent communication and collaboration abilities.

MINIMAL

QUALIFICATIONS:

* Education:

RN, LPN, LVN.

* Experience:

* 2+ years of clinical experience in a healthcare setting.

* Prior experience with HEDIS abstraction or utilization review strongly preferred.

* License:
Florida unrestricted license

* BLS certification

* Computer literacy

KNOWLEDGE AND

SKILLS:

* Knowledge of current professional nursing theory, practice, and techniques

* Knowledge of current nursing practices in an outpatient primary care setting

* Knowledge of assessment of patient needs and services

* Knowledge of current professional nursing and pharmaceutical products, Universal Precautions, and emergency situations

* Knowledge of basic pathophysiology of diseases commonly managed in Family Medicine

* Knowledge of the application of nursing techniques (example: Triage, blood pressure monitoring, glucose monitoring, etc.)

* Knowledge of patient teaching and education (example: self-blood pressure monitoring, nutrition instruction, diabetes self-care instruction)

* Knowledge of general patient care and treatment procedures, equipment, rules, regulations, and ethics

* Knowledge of Utilization Review Accreditation Commission (URAC) Policies and Procedures

* Knowledge of processing and obtaining prior authorizations

* Knowledge of making observations of general physical condition and needs of patients and when to confer with a physician about the emotional or physical condition of a patient

* Knowledge of the principles of aseptic and sterile techniques and infection control techniques

* Knowledge of the techniques of administration of common medications, including immunizations, inoculations, and allergy injections using sterile technique, and knowledge of the side effects of these medications

* Knowledge of state and federal drug control laws, rules, and regulations

* Knowledge of emergency techniques and procedures

* Knowledge of common medical supplies and equipment

* Excellent interpersonal, communication and leadership skills

* Ability to demonstrate priority-setting and ability to work in a complex environment

* Ability to function with a high degree of independence and collaboration with other health care providers

* Commitment to service, quality, and departmental core values

RESPONSIBILTIES AND PERFORMANCE EXPECTATIONS include, but are not limited to, the following:

* Be familiar with CFHC's program philosophies, goals and objectives. Be cognizant of and comply with all CFHC's policies and procedures, as well as state and federal regulations.

* Be competent in performing the duties of a nurse.

* Understand the requirements of CFHC's Exposure Control Plan. Personally, utilize universal precautions when practicing in a clinical setting.

* Participate in staff outreach and off-site health care programs as requested by…