Who we are
Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.
Our commitment is to:
- Strive to apply an equity lens to all our work.
- Reduce health disparities.
- Become an anti-racist organization.
- Create an equitable work environment.
About the Role
The HEDIS Quality Improvement Nurse is responsible for performing medical record review audits and analysis for regulatory National Committee for Quality Assurance (NCQA) and Centers for Medicare & Medicaid Services (CMS) audits. This role supports assisting the Manager with developing provider audit reports, provider education, identifying opportunities for process improvement, performs overread and peer review of other team member output.
To be successful in this role, you:
- Are a Licensed Registered Nurse (RN) or License Practical Nurse (LPN).
- Have a minimum of five (5) years combined experience performing NCQA, Health Effectiveness Data and Information Set (HEDIS) and CMS Medicare Star measure medical record and coding review AND conducting documentation and coding
- Have experience with Microsoft Office Suite (Word, Excel, Outlook, and Internet Explorer) and Adobe Acrobat, including comfort with pivot tables at a minimum. Experience with SharePoint, Confluence, and Smartsheet is advantageous.
- Have bachelor’s degree in nursing or an equivalent combination of education and highly relevant experience preferred.
- Have knowledge and experience with NLP, computer assisted medical record review and coding applications (preferred).
- Have an applied understanding of principles of reimbursement-based CMS Medicare Stars and State Value Base program experience preferred.
Essential functions and Roles and Responsibilities:
- Support updating and maintaining CHPW HEDIS medical record review and coding guidelines to reflect changes of the NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes. Interpret changes and support modifying CHPW policies in coordination with HEDIS Performance Measurement Manager and HEDIS Program Manager.
- Keep current on regulatory, medical record documentation and coding issues/best practices including NCQA Guidelines for Medical Record Documentation, Coding and Reporting.
- Present findings via verbal and written updates to internal audiences including peer to peer, department leadership reporting, provider and clinical teams, and vendor support teams.
- Update and distribute provider feedback reports to HEDIS Performance Manager as needed for identifying provider performance trends and participate in creating materials for all significant audit findings including trends and associated recommendations (e.g., training, oversight, monitoring, process flow changes, documentation, and coding education) specific to internal departments, coding vendors, and others.
- Serve as medical record review and coding SME. Support overread and validation of other colleagues’ documentation performance.
- Complete the annual regulatory HEDIS medical record review and coding quality assurance process and workflow of the primary source validation and retrospective medical record and coding audit.
- Identify and implement practices and Quality Assurance process improvement
- Monitor and comply with internal medical record and coding guidelines, department policies, and NCQA/CMS quality program guidelines, rules, and regulations.
- Continuous development of knowledge in Medicare, Medicaid, and Exchange programs to ensure timely review of regulatory medical record documentation and coding best practices including NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes.
- Support chart audit processes, including provider and vendor documentation of required medical record documentation and coding to ensure adherence with NCQA HEDIS and CMS Medicare Stars guidelines.
- Act as a liaison between internal departments on regulatory data validation audits (including Primary Source Validation, Prospective Medical Record Review and Retrospective (Hybrid) Medical Record Review.).
- Perform root cause analysis to identify issues that may contribute to medical record documentation and coding
- Perform internal and external coding quality reviews to validate correct medical record documentation and coding
- Other duties as Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion
Knowledge, Skills, and Abilities:
- Knowledge of acceptable medical record and coding standards and criteria in the context of NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes.
- Strong written and verbal communication
- Strong organizational, time management skills, and prioritization of work.
- Ability to design and update provider feedback report
- Strong analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.
As part of our hiring process, the following criteria must be met:
- Complete and successfully pass a criminal background check.
Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.
- Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
- Vaccination requirement (CHPW offers a process for medical or religious exemptions)
- Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation
Compensation and Benefits:
The position is FLSA Exempt and is not eligible for overtime. Based on market data, this position grade is (66 and has a (10%) annual incentive target based on company, department, and individual performance goals.
CHPW offers the following benefits for Full and Part-time employees and their dependents:
- Medical, Prescription, Dental, and Vision
- Telehealth app
- Flexible Spending Accounts, Health Savings Accounts
- Basic Life AD&D, Short and Long-Term Disability
- Voluntary Life, Critical Care, and Long-Term Care Insurance
- 401(k) Retirement and generous employer match
- Employee Assistance Program and Mental Fitness app
- Financial Coaching, Identity Theft Protection
- Time off including PTO accrual starting at 17 days per year.
- 40 hours Community Service volunteer time
- 10 standard holidays, 2 floating holidays
- Compassion time off, jury duty pay.
Sensory/Physical/Mental Requirements:
Sensory*:
- Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.
Physical*:
- Extended periods of sitting, computer use, talking, and possibly standing.
- Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.
- Frequent torso/back static position; occasional stooping, bending, and twisting.
Mental:
- Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.
Work Environment:
Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.