HEDIS Case Manager

Overview

As Needed HEDIS Case Manager

Cal Optima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a HEDIS Case Manager
- As Needed and help shape the future of healthcare where you ll be an integral part of our Quality Analytics team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The HEDIS Case Manager will be responsible for reviewing and abstracting medical records for the annual and year-round Healthcare Effectiveness Data and Information Set (HEDIS) project. You ll review assigned medical records to determine if documentation meets HEDIS measurement specifications set by the National Committee for Quality Assurance (NCQA) and enter all findings into the NCQA certified software daily. Additionally, you ll need to meet daily productivity and data entry accuracy goals, participate in medical record collection, and request and abstract additional medical records found through the pursuit process.

Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 95% - Program Support
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Conducts medical record review according to the current NCQA HEDIS® Technical Specifications.
• Enters all data and findings into the NCQA certified software. All nurse abstractors/over-readers are required to pass inter-rater reliability testing for all measures at a 5% error threshold.
• Requests medical records as appropriate from practitioner offices, clinics, hospitals and other clinical facilities.
• Identifies and effectively communicates trends found in medical record review to the HEDIS team.
• Attends weekly and ad-hoc meetings and trainings as needed.
• Abides by the Health Insurance Portability and Accountability Act (HIPAA) and associated patient confidentiality requirements.
• 5%- Other
• Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• High school diploma or equivalent PLUS 3 years of nursing experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

You'll Stand Out More If You Possess the Following:

• Associate Degree in Nursing (ADN) or related field.
• Current, unrestricted Registered Nurse (RN) to practice in the state of California.
• Relevant experience in medical records management or Quality Improvement (QI) experience with the proven ability to read and interpret medical record data for chart audits or abstractions.

What the Regulatory Agencies Need You to Possess?

• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California required.

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with Cal Optima Health s leadership and staff and external contacts at all levels and with diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events.
• Organize, be analytical, problem-solve and possess project management skills.
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.
• Ability to speak (enunciate) clearly in conversation and general communication.
• Hearing ability for verbal communication/conversation/responses via…