HEDIS Abstractor and Overreader

Position Summary:

The HEDIS Abstractor and Overreader is responsible for the HEDIS Medical Record Review (MRR) process which includes accurately reviewing and abstracting medical records to determine compliance with HEDIS measure specifications, as well as conducting overreads to ensure data quality, consistency and adherence to NCQA guidelines.  This role will work closely with internal and external stakeholders to ensure medical charts meet standards as outlined by HEDIS specifications and will partner with health plans to understand correct and consistent implementation of audit and testing processes for HEDIS measures.

Essential Job Functions:

• Review and abstract clinical data from electronic medical records in alignment with HEDIS technical specifications
• Perform overreads of abstracted medical records for accuracy, completeness and measure compliance
• Demonstrate high level of proficiency in HEDIS measures and coding standards (including but not limited to ICD-10, CPT and CPTII) to close gaps in care
• Collaborate with internal and external partners to resolve documentation discrepancies and provide recommendations for improvement
• Support audit preparation and participate in internal quality reviews and training sessions
• Manages all activities to meet health plan contractual and reporting timeframes
• Identify trends in abstraction that may impact measure performance or audit readiness and proactively escalate to leadership

Other Job Functions:

• Other duties as assigned.

Required Qualifications:

Minimum Experience

• Minimum of 2 years’ experience working with NCQA HEDIS programs and/or HEDIS abstraction in all measures
• Proficiency in EMR platforms (i.e., Epic, Cerner) and abstraction tools
• Familiarity with Medicare Advantage lines of business and Stars Measures
• Familiarity with supplemental data processes and quality data integration

Education & Licensure

• Minimum of Bachelor’s degree or equivalent degree

Skills and Abilities:

• Ability to be a team player and exercise initiative in responding to team members or Sr. Manager.
• Thorough understanding of medical record documentation and medical terminology
• High level of attention to detail and ability to follow direction on project deadlines
• Ability to work independently
• Strong language skills in English speaking and understanding
• Ability to meet high productivity requirements and Interrater Reliability standards
• Strong Excel skills
• Ability to interpret compliance vs non-compliance on health plan gap file use to direct abstraction efforts.
• Ability to apply deep level of measure understanding to legal medical records
• Strong Adobe skills (including saving records in PDF format and annotation)
• Ability to interpret large data files for needed abstraction
• Deep level of ability to recognize medical records that are not complete or are missing needed data points in overreading
• Ability to report clearly on both positive or negative findings and apply possible solutions on Team calls