CrawlJobs Logo
Robert Half Logo Robert Half · Nursing

Clinical Quality HEDIS Reviewer

United States, Eden Prairie · Job Posted March 01, 2026
Apply Position
Job Link Share

Job Description

This role performs ongoing analysis of charts for various STARS and HEDIS® quality measures. The information obtained during these reviews will work to close quality measure gaps as well drive other teams work on provider education on behalf of the insurance plan. Individual must be highly organized, possess strong critical thinking skills, with demonstrated professional maturity and emotional resilience. Day to day work varies based on time of year, with overarching goal to generate completely accurate chart abstraction resulting in improved HEDIS® or other quality program rates. The role requires utilization of multiple sources of information, medical record collection tracking tools, and electronic medical record systems.

Job Responsibility

  • Support chart chase processes by requesting records from provider offices as needed
  • Primary source verify abstracted medical record data
  • Over read abstracted and verified medical record data
  • Analyze chart data evaluate for possible data integrity and/or data deficits and document findings
  • Provide education and feedback to primary source verifiers and/or abstractors
  • Meet and maintain production and quality expectations for all assigned measures
  • Responsible for managing and utilizing confidential information from medical records in an appropriate manner following designated guidelines including HIPAA and company policies/guidelines
  • Support Chart Chase Review and abstract medical record data into appropriate applications
  • Navigate multiple documentation systems and obtain medical record sections supportive of HEDIS/Star measures
  • Applies HEDIS® concepts and principles in the completion of abstraction and review process to ensure full recognition of delivered care for the benefit of the member
  • Transition between priorities and abstraction projects based on program or client needs
  • Ability to work in a self-directive manner and apply critical thinking/problem solving skills by referencing available Technical Specifications, Business Process Documentation, Job Aids, and other tools for clarity/guidance as needed

Requirements

  • Registered Nurse
  • Two or more years of HEDIS/STAR experience
  • Three or more years of experience with data analysis/quality chart reviews
  • Must be able to review data and provide recommendations for improvement
  • Excellent communication practices both oral and written
  • Experience using Microsoft office applications including databases word-processing and Excel spreadsheets
  • Designated workplace at home free of distractions
  • Reliable, highspeed internet connection
  • Ability to contact providers and request data independently, by telephone and in writing
  • Experience and confidence with placing outbound phone calls
  • Proficient in Microsoft Office applications including Excel, Outlook, Word

What we offer

  • medical
  • vision
  • dental
  • life and disability insurance
  • 401(k) plan
Robert Half - All Job Offers

Looking for more opportunities?

Search for other job offers that match your skills and interests.

Suggested Tags: Frontend Developer Secretary Talent Manager Salesforce Administrator Data Analyst
Similar Jobs for

Clinical Quality HEDIS Reviewer

8 matching positions

Senior Manager, Stars and Clinical Initiatives

The Senior Manager, Stars and Clinical Initiatives is responsible for developing...
Location
Location
United States , Los Angeles
Salary
Salary:
135136.00 - 216218.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree
  • At least 7 years of Medicare Stars experience including experience driving measurable improvement in quality metrics and Star ratings within a health plan
  • At least 5 years of leadership experience with proven ability to motivate and develop team members
  • At least 5 years of leading staff, supervisor/management experience
  • Experience leading and supporting initiatives aimed at transforming care delivery and improving health outcomes for vulnerable populations through a service-oriented, mission-driven approach
  • Experience leading teams, projects, or cross-functional groups
  • Deep knowledge of Stars, Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPs), and related quality improvement programs
  • Strong knowledge of CMS and state regulatory standards and industry trends
  • Excellent analytic skills to conduct analysis and develop recommendations with proficiency in Stars data analysis, performance modeling, and reporting
  • Ability to work across functions and build strong collaboration and partnership with diverse internal and external stakeholders
Job Responsibility
Job Responsibility
  • Lead the development, implementation, and continuous improvement of clinical and quality improvement programs that support D-SNP and Covered California Star performance
  • Collaborate closely and build cross-functional alignment with internal teams to develop and implement evidence-based best practices
  • Serve as Medicare and Covered California Stars subject matter expert and strategic thinker while also being a hands-on, operational and execution-focused leader
  • Analyze data, distill actional insights, and incorporate into program evaluations and data-driven continuous improvement strategies
  • Deliver reports to required committees and workgroups
  • Stay updated on industry trends and best practices including around the application of Artificial Intelligence (AI) tools to improve quality of care, member experience, and member outcomes
  • Support the adoption of new technology and innovation to elevate Stars performance and member outcomes
  • Engage with external stakeholders including vendors, community organizations, and other solution providers to build new partnerships that elevate Stars performance and services for members
  • Identify and manage Centers for Medicare and Medicaid Services (CMS) and state regulatory updates and risks to ensure compliance with standards
  • Execute risk mitigation activities
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

Manager, Quality Data

The Manager of Quality Data is an important role on the quality data team. This ...
Location
Location
United States , Los Angeles
Salary
Salary:
117509.00 - 188015.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's Degree in Mathematics or Economics
  • In lieu of degree, equivalent education and/or experience may be considered
  • At least 6 years of clinical outcomes review and quality data experience with strong skills in data validation
  • At least 4 years of leading staff or supervisory/management experience
  • At least 3 years of experience with HEDIS and Surveys for example, Consumer Assessment of Healthcare Providers and Systems (CAHPS), Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS), Consumer Assessment of Healthcare Providers and Systems Medicare Advantage and Prescription Drug Plan (CAHPS- MAPD), Qualified Health Plan Enrollee Experience Survey (QHP-EES), Health Outcome Survey (HOS), etc
  • Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement
  • Communication skills with technical staff in a NCQA accredited health plan
  • Advanced programming skills working with data types such as membership, provider, claims and encounters
  • Working knowledge of MS Access, Excel, and Word software
  • Able to manage project timelines, requested deliverables and developing and maintaining prioritization thereof
Job Responsibility
Job Responsibility
  • Manages the HEDIS and Survey Projects: Updates internal policies and procedures that pertain to functions related to data process, data collection, and Health Insurance Portability and Accountability Act (HIPAA) compliance. Present to groups as needed
  • Staff support and administration
  • Works with staff to set up incentive goals, and work metrics
  • Monitors activity to assure staff are engaged
  • Works with the technical staff to develop databases for data capture and reporting
  • Conducts verbal or written counseling, writes performance improvement plans, and resolves issues impacting productivity
  • Works with and presents to Plan Partners and provider groups to optimize data quality and completeness
  • Works with the technical staff to produce and assure the delivery of reports for submissions required by NCQA, Centers for Medicare and Medicaid Services (CMS), Managed Risk Medical Insurance Board (MRMIB), and other regulatory or accreditation agencies
  • Resolves issues impacting delays in timelines, staffing, and/or production
  • Initiates and participates in performance/quality improvement initiatives and workgroups
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

FEP Clinical Pharmacist

Provide utilization and drug interaction of drug therapies to include review of ...
Location
Location
United States , Phoenix
Salary
Salary:
Not provided
azblue.com Logo
Blue Cross Blue Shield of Arizona
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • 3 years or more as a practicing pharmacist
  • 3 years or more experience in the managed care pharmacy field
  • Doctor of Pharmacy (Pharm.D) degree
  • Active, current and unrestricted State of Arizona (a state in the United States) pharmacist license
  • Specialty certification in Medication Therapy Management (may obtain certification within 6 months of job entry)
  • Proficient in critical literature evaluation skills, including evidence-based medicine principles
  • Excellent problem-solving skills
  • Strong written and verbal communications
  • Strong PC proficiency
  • Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Job Responsibility
Job Responsibility
  • Collaborate with FEP Management, FEP Operations, and FEP HEDIS to create clear communication to FEP members and/or network providers on medication therapy recommendations
  • Work in partnership with FEPDO and Pharmacy Management team
  • Regularly collaborate with other plan pharmacy reps and programs
  • Collaborate with FEP Management and HEDIS staff for targeted FEP ongoing initiatives
  • Act as a clinical resource to FEP internal staff regarding medication therapy
  • Evaluate medication related problems such as adverse events, therapeutic duplication, adherence to therapy, polypharmacy, and untreated disease or conditions
  • Analyzes, documents, and reports member outreach and intervention performance results as required by the FEP Medication Therapy Management Program (MTM Program)
  • Provide education and training on the appropriate use of medications to monitor and evaluate patient’s response to therapy
  • Document all interventions via a medication related action plan or care plan (CP)
  • Support and resolve pharmacy related member specific benefit issues
  • Fulltime
Read More
Arrow Right

Licensed Nurse Care Coordinator Senior - Quality Management

An LVN/ LPN plays a crucial role in managing patient care and ensuring continuit...
Location
Location
United States , Tyler
Salary
Salary:
Not provided
christushealth.org Logo
CHRISTUS Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • High School Diploma required
  • Minimum of 3 years of clinical or home health experience required
  • 5 years supporting value-based care programs, accountable care organizations, or HEDIS
  • Knowledge of government programs (CMS), accountable care organizations (ACOs), HEDIS, and experience with payor cost sharing initiatives preferred
  • Knowledge of physician office practice operations and 3 years of experience in a physician practice is preferred
  • Proficiency in keyboarding and EHR systems, primarily Epic
  • LVN/ LPN in the state of employment and/or compact licensure required
Job Responsibility
Job Responsibility
  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders
  • Mentor, train and support the team of care coordinators, ensuring high-quality care and adherence to best practices. Assist with work assignments and development of new work processes as needed. Coordinate and assist with associate onboarding. Create education material for training
  • Monitor and ensure compliance with all regulatory requirements, organizational policies, standing delegated orders and protocols
  • Identify quality gaps and risk adjustment gaps. Participate in Quality Improvement Programs as indicated. Attend learning sessions and share information learned with team members. Assist in the development of tools, education, and workflow processes to assist the network in meeting CMS, ACO, documentation, and payor quality initiatives
  • Conducts internal review audits to facilitate feedback for documentation and efficiency of the care coordination team
  • Support Primary Care Providers and assist patients in scheduling preventative screenings and appropriate appointments. Maintain ongoing communication with healthcare providers through various tools and meetings
  • Monitor value-based care quality performance and pulls reports to identify open care gaps. Conducts telephonic outreach on behalf of providers to close care gaps & address medication adherence to facilitate star rating and quality performance
  • Providing counseling and health education to patients and families, using appropriate materials and standardized protocols. Serve as a subject matter expert in care transitions & quality metrics. Assist in educating practice staff on quality, payor, and government program requirements
  • Communicate resources and services available to patients through the continuum of care
  • Escalate health concerns to Primary Care providers and place referrals to appropriate care team members, i.e., Nurse Navigation, CHW, etc. Develop professional working relationships with ACO and CIN network providers, practice managers, and their staff to collaboratively manage follow-up care and improve overall health and wellness. Conduct in-person and virtual meetings with practice managers, staff, providers and managers to communicate program goals, results, and provide education
  • Fulltime
Read More
Arrow Right

Manager / Director Business Analytics

We are looking for Job Title: Manager / Director Business Analytics. We are seek...
Location
Location
United States
Salary
Salary:
Not provided
spectramedix.com Logo
SpectraMedix
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • 12+ years of experience in healthcare analytics, management consulting, actuarial consulting, payer strategy, or value-based care environments
  • Deep knowledge of healthcare economics, payer operations, and value-based care performance drivers
  • Strong understanding of HEDIS, NCQA, Stars, risk adjustment, utilization management, and provider incentive models
  • Proven ability to analyze large healthcare datasets including claims, pharmacy, eligibility, provider, and clinical data
  • Strong financial modeling skills including ROI, PMPM analysis, trend forecasting, and scenario modeling
  • Experience presenting to executive audiences and influencing senior stakeholders
  • Demonstrated success leading complex client engagements and delivering measurable outcomes
  • Experience managing teams, developing talent, and overseeing high-quality work product
  • Strong technical fluency with SQL, Excel, and BI platforms such as Tableau or Microsoft Power BI
  • Excellent written and verbal communication skills with strong executive presence
Job Responsibility
Job Responsibility
  • Strategic Client Advisory: Serve as a trusted advisor to executive client stakeholders across analytics, network, finance, quality, and value-based care functions
  • Translate complex performance data into clear strategic recommendations tied to quality improvement, MLR performance, provider engagement, and financial outcomes
  • Lead executive presentations, steering committees and high-impact client discussions
  • Identify growth opportunities, operational risks, and emerging market trends affecting client performance
  • Value-Based Care Leadership: Demonstrated experience navigating the intricacies of VBC contract language (e.g., attribution logic, risk adjustment factors, and benchmark methodology)
  • Advise clients on value-based care models including pay-for-performance, shared savings, downside risk, capitation, and incentive programs
  • Interpret HEDIS, NCQA, Stars, risk adjustment, and utilization metrics within the context of provider contracts and health plan economics
  • Delivery Excellence & Scalable Execution: Establish rigorous standards for data quality, reconciliation, methodology transparency, and audit readiness
  • Build repeatable reporting frameworks, templates, and scalable processes that improve efficiency and consistency
  • Identify automation opportunities across recurring reporting, dashboard production, and insight generation
  • Fulltime
Read More
Arrow Right

Senior Healthcare Informatics Analyst - Pharmacy

The Senior Healthcare Informatics Analyst – Pharmacy Analytics role focuses on p...
Location
Location
United States , Baton Rouge
Salary
Salary:
Not provided
nttdata.com Logo
NTT DATA
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • 4 years of healthcare analytics experience, with pharmacy or PBM analytics experience strongly preferred
  • 3 years experience analyzing pharmacy claims, formulary performance, drug mix, utilization trends, rebates, and adherence metrics (PDC/MPR)
  • 2 years experience/advanced knowledge of SAS (including Enterprise Miner) preferred
  • 3 years experience with SQL, SAS, R, Python, Tableau, or similar analytic/visualization tools
  • Bachelors degree in healthcare administration, pharmacy, public health, statistics, economics, analytics, computer science, or related field required
  • Masters degree in a related field preferred
  • Strong critical thinking, analytical, and problem-solving skills
  • Experience building predictive and explanatory models related to pharmacy utilization, cost, and outcomes
  • Knowledge of pharmacy outcomes research, utilization management, and drug trend analysis preferred
  • Strong working knowledge of the U.S. healthcare system in a payer setting, with specific understanding of pharmacy benefits and PBM operations
Job Responsibility
Job Responsibility
  • Leads the selection and application of pharmacy-focused analytic, evaluation, and BI methodologies to support business decisions and strategic planning
  • Leverages pharmacy claims data, PBM feeds, EDW data sources, and non-EDW datasets to deliver actionable insights
  • Independently partners with business teams to define pharmacy analytics needs and develop solutions such as predictive models, dashboards, utilization analyses, and performance metrics
  • Serves as a pharmacy analytics advisor on enterprise and cross-functional initiatives
  • Translates pharmacy business rules and policies into analytical models and reporting solutions, acting as a liaison between Pharmacy, Analytics, IT, and EIM teams
  • Performs peer data quality reviews to ensure accuracy, completeness, and consistency of pharmacy analytics output
  • Conducts advanced descriptive and statistical analyses related to drug utilization, adherence, cost drivers, and clinical outcomes
Read More
Arrow Right

Epic Sr. Analyst

The Epic Sr. Analyst - You and the team will initiate the implementation, builds...
Location
Location
United States , Miami
Salary
Salary:
Not provided
https://www.roberthalf.com Logo
Robert Half
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor’s degree
  • Epic Healthy Planet or Ambulatory Certification
  • 3 years of experience in healthcare‑related organization
  • Skills in operations, project management, organization
  • Familiarity with case/care management workflows and wellness programs
  • Familiarity with quality reporting for MA, ACO/MSSP, MU
  • Familiarity with health plan workflows and claims ingestion
  • Strong communication and interpersonal skills
  • Problem‑solving ability
  • Ability to lead, train, and motivate
Job Responsibility
Job Responsibility
  • Collaborates with key stakeholders, end-users, and application team members to optimize the application's configuration, function, and access
  • Serves as a primary support contact for application end-users
  • Initiates the design, development, implementation, and maintenance of the application
  • Initiates all phases of testing and the documentation of workflow design
  • Performs the analysis of information technology in clinical work processes and validates the impacts to the workflow
  • Initiates the identification of issues and guides the work to resolve them
  • Supports junior staff members in evaluation and resolution of service tickets, implementing changes, retrieving data, and day‑to‑day operations
  • Collaborates with trainers on application changes and new features
  • Works with stakeholders, business community, and end users to ensure application meets the needs
  • Participates in on‑call rotations and committees
What we offer
What we offer
  • medical, vision, dental, and life and disability insurance
  • company 401(k) plan
  • free online training
Read More
Arrow Right

Manager, Quality Data

The Manager of Quality Data is an important role on the quality data team. This ...
Location
Location
United States , Los Angeles
Salary
Salary:
117509.00 - 188015.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • At least 6 years of clinical outcomes review and quality data experience with strong skills in data validation
  • At least 4 years of leading staff or supervisory/management experience
  • At least 3 years of experience with HEDIS and Surveys for example, Consumer Assessment of Healthcare Providers and Systems (CAHPS), Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS), Consumer Assessment of Healthcare Providers and Systems Medicare Advantage and Prescription Drug Plan (CAHPS- MAPD), Qualified Health Plan Enrollee Experience Survey (QHP-EES), Health Outcome Survey (HOS), etc.
  • Communication skills with technical staff in a NCQA accredited health plan
  • Advanced programming skills working with data types such as membership, provider, claims and encounters
  • Working knowledge of MS Access, Excel, and Word software
  • Able to manage project timelines, requested deliverables and developing and maintaining prioritization thereof
Job Responsibility
Job Responsibility
  • Manages the HEDIS and Survey Projects: Updates internal policies and procedures that pertain to functions related to data process, data collection, and Health Insurance Portability and Accountability Act (HIPAA) compliance
  • Staff support and administration
  • Works with staff to set up incentive goals, and work metrics
  • Works with the technical staff to produce and assure the delivery of reports for submissions required by NCQA, Centers for Medicare and Medicaid Services (CMS), Managed Risk Medical Insurance Board (MRMIB), and other regulatory or accreditation agencies
  • Resolves issues impacting delays in timelines, staffing, and/or production
  • Initiates and participates in performance/quality improvement initiatives and workgroups
  • Sets work standards and monitors production as indicated by the project plan
  • Oversight of data vendor services
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right