Fallon Health Nurse Reviewer HEDIS-Per Diem in Worcester, Massachusetts

Overview

About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Brief summary of purpose :

With supervision from the Senior Manager of Quality Services, the Nurse Reviewer – HEDIS is accountable for the review of clinical quality data for the purpose of HEDIS® reporting. Projects include medical record data abstraction from multiple sources. The nurse provides clinical expertise, technical support and data analysis for HEDIS measures.

Responsibilities

Primary job responsibilities:

  • Reviews medical records according to the HEDIS® technical specifications.

  • Maintains a 96% inter-rater reliability score for reviewed HEDIS® measures.

  • Performs on-site medical record review at designated medical facilities as requested using standardized criteria.

  • Provides clinical expertise and documentation of HEDIS®requirements.

Qualifications

Education, Licenses, certification and experience requirements:

Education: Degree in nursing (Baccalaureate preferred) with a current Massachusetts nursing license. *     *

License: LPN or RN *    *

Certification: *     *

Experience: Minimum of 5 years related experience in healthcare setting including hospital medical/surgical and ambulatory care. Quality management/performance improvement experience preferred. Must possess strong interpersonal, analytical, and communications skills. Ability to multi-task a desired quality. *   *

Job ID 5524

# Positions 1

Category Nursing

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