Title: HEDIS Utilization Review Nurse Reports to: Director of Managed Care FLSA Status: Exempt Personnel Supervised: None
POSITION SUMMARY:
The HEDIS Utilization Review Specialist is responsible for performing comprehensive reviews of medical records to collect data required for HEDIS reporting. This role supports quality improvement initiatives by identifying gaps in care, validating clinical documentation, and ensuring compliance with NCQA (National Committee for Quality Assurance) standards.
KEY RESPONSIBILITIES:
Review medical records and clinical data for HEDIS-specific measures.
Abstract and input accurate clinical data from electronic health records (EHRs) into reporting tools.
Identify and report documentation deficiencies or care gaps.
Collaborate with providers, coders, and clinical teams to ensure proper documentation and follow‑up.
Assist in the coordination and execution of the annual HEDIS data collection cycle.
Maintain knowledge of current HEDIS specifications and regulatory updates.
Support audits and internal quality improvement initiatives related to clinical outcomes.
Ensure HIPAA compliance and confidentiality of patient information.
SKILLS:
Strong knowledge of HEDIS measures and NCQA guidelines.
Proficient in EHR systems and chart review processes.
Detail‑oriented with strong analytical and organizational skills.
Excellent communication and collaboration abilities.
MINIMAL QUALIFICATIONS:
Education: RN, LPN, LVN.
Experience:
2+ years of clinical experience in a healthcare setting.
Prior experience with HEDIS abstraction or utilization review strongly preferred.
BLS certification
KNOWLEDGE AND SKILLS:
Knowledge of current professional nursing theory, practice, and techniques.
Knowledge of current nursing practices in an outpatient primary care setting.
Knowledge of assessment of patient needs and services.
Knowledge of current professional nursing and pharmaceutical products, Universal Precautions, and emergency situations.
Knowledge of basic pathophysiology of diseases commonly managed in Family Medicine.
Knowledge of the application of nursing techniques (example: Triage, blood pressure monitoring, glucose monitoring, etc.).
Knowledge of patient teaching and education (example: self‑blood pressure monitoring, nutrition instruction, diabetes self‑care instruction).
Knowledge of general patient care and treatment procedures, equipment, rules, regulations, and ethics.
Knowledge of Utilization Review Accreditation Commission (URAC) Policies and Procedures.
Knowledge of processing and obtaining prior authorizations.
Knowledge of making observations of general physical condition and needs of patients and when to confer with a physician about the emotional or physical condition of a patient.
Knowledge of the principles of aseptic and sterile techniques and infection control techniques.
Knowledge of the techniques of administration of common medications, including immunizations, inoculations, and allergy injections using sterile technique, and knowledge of the side effects of these medications.
Knowledge of state and federal drug control laws, rules, and regulations.
Knowledge of emergency techniques and procedures.
Knowledge of common medical supplies and equipment.
Excellent interpersonal, communication and leadership skills.
Ability to demonstrate priority‑setting and ability to work in a complex environment.
Ability to function with a high degree of independence and collaboration with other health care providers.
Commitment to service, quality, and departmental core values.
RESPONSIBILTIES AND PERFORMANCE EXPECTATIONS include, but are not limited to, the following:
Be familiar with CFHC’s program philosophies, goals and objectives. Be cognizant of and comply with all CFHC’s policies and procedures, as well as state and federal regulations.
Be competent in performing the duties of a nurse.
Understand the requirements of CFHC’s Exposure Control Plan. Personally, utilize universal precautions when practicing in a clinical setting.
Participate in staff outreach and off‑site health care programs as requested by the DMC, ACMO, CMO, or CEO. Represent CFHC in the community.
Report as needed to DMC and any pertinent information or situations that impact on patient care or CFHC liability.
Attend and participate in mandatory CFHC meetings (Center Specific meetings, Corporate meetings, and other meetings as designated by the DMC, ACMO, CMO, or CEO).
Demonstrate ability to work cooperatively with other members of the clinical team. Be supportive of coworkers.
Maintain a neat and professional appearance at all times.
Carry out any other activities deemed appropriate by the DMC, CMO, or CEO.
Primary Duties include, but are not limited to, the following:
Assess, identify problems, plan goals, monitor and evaluate patient plans, and develop strategies that meet the patient’s immediate and long‑term goals.
Work closely with PCP to manage patient “care items” which could include medication refills per protocol, lab triage, document management, management of durable medical equipment (i.e. Glucometer, test strips, lancets), prior authorizations of needed medications or other services.
Use patient data to track and schedule follow‑up appointments.
Provide proactive utilization management for patients with high risk needs.
Assist patients in obtaining appropriate medications and medical supplies and equipment, including coordination of pharmaceutical patient assistance programs.
Participate in quality improvement, quality assurance and innovation activities to ensure optimal level of care delivery.
This position will ensure all HEDIS measures have been met for those assigned patients and all care gaps have been identified.
Assist in the coordination of warm hand‑offs or “transfer of trust” between care team, pharmacy or other support services during the office visit.
Carry out other duties as assigned by the DMC.
*This organization reserves the right to revise or change job duties and responsibilities as the need arises. This job description does not constitute a written or implied contract or employment.*
BENEFITS:
Federal Student Loan Forgiveness: PSLF – 10‑year commitment, 120 loan payments and at the end of the commitment, the remaining loan is forgiven.
Excellent medical, dental, vision, and pharmacy benefits.
Employer Paid Long‑Term Disability Insurance.
Employer Paid Life Insurance equivalent to 1x your annual salary.
Voluntary Short‑Term Disability; additional Life and Dependent Life Insurance are available.
Malpractice Insurance.
Paid Time Off (PTO) – 4.4 weeks per year pro‑rated.
Holidays (9.5 paid holidays per year).
Paid Birthday Holiday.
CME Reimbursement.
401k Retirement Plan after 1 year of service (w/matching contributions).
Staff productivity is recognized and rewarded.
PHYSICAL REQUIREMENTS
Requires 80% or more time spent sedentary.
Independently mobile.
Ability to lift weight equivalents that would be required with re‑positioning equipment and lifting supplies.
Ability to adapt and function in varying environments of workload, patient acuity, work sites, and work shifts.
American with Disabilities Act (ADA) Statement: External and internal applicants, as well as position incumbents who become disabled, must be able to perform the essential job specific functions (listed within each job responsibility) either unaided or with the assistance of a reasonable accommodation to be determined by the organization on a case by case basis.