Working Each Day to Make a Difference
At Community Health Plan of Washington, we’re driven by our belief that everyone deserves access to quality health care.
More than 25 years ago, we made a commitment to improve the health of our communities by making quality health care accessible to all Washington state residents.
We continue that pledge today by providing affordable comprehensive coverage to more than 315,000 individuals and families throughout the state.
- We are a local not-for-profit health plan in Washington State.
- We are committed to keeping Washington families healthy.
- We connect our communities to the health resources they need.
- We provide access to high-quality care for our members.
- We connect and empower our members through technology.
- The Community Health Centers we partner with strive to support members with a comprehensive mix of medical resources in one convenient location.
- Our partnerships with Community Health Centers and our extended provider network help us improve the health care delivery system.
To learn more about how you can make a difference working at Community Health Plan of Washington, visitwww.chpw.org.
HEDIS Quality Improvement Nurse
This position is available fully remote within Washington State
POSITION PURPOSE:
The HEDIS Quality Improvement Nurse is responsible for performing medical record review audits and analysis for regulatory National Committee for Quality Assurance (NCQA) and Centers for Medicare & Medicaid Services (CMS) audits. This role supports assisting the Manager with developing provider audit reports, provider education, identifying opportunities for process improvement, performs overread and peer review of other team member output.
PRINCIPAL DUTIES:
- Support updating and maintaining CHPW HEDIS medical record review and coding guidelines to reflect changes of the NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes. Interpret changes and support modifying CHPW policies in coordination with HEDIS Performance Measurement Manager and HEDIS Program Manager.
- Keep current on regulatory, medical record documentation and coding issues/best practices including NCQA Guidelines for Medical Record Documentation, Coding and Reporting.
- Present findings via verbal and written updates to internal audiences including peer to peer, department leadership reporting, provider and clinical teams, and vendor support teams.
- Update and distribute provider feedback reports to HEDIS Performance Manager as needed for identifying provider performance trends and participate in creating materials for all significant audit findings including trends and associated recommendations (e.g., training, oversight, monitoring, process flow changes, documentation, and coding education) specific to internal departments, coding vendors, and others.
- Serve as medical record review and coding SME. Support overread and validation of other colleagues’ documentation performance.
- Complete the annual regulatory HEDIS medical record review and coding quality assurance process and workflow of the primary source validation and retrospective medical record and coding audit.
- Identify and implement practices and Quality Assurance process improvement.
- Monitor and comply with internal medical record and coding guidelines, department policies, and NCQA/CMS quality program guidelines, rules, and regulations.
- Continuous development of knowledge in Medicare, Medicaid, and Exchange programs to ensure timely review of regulatory medical record documentation and coding best practices including NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes.
- Support chart audit processes, including provider and vendor documentation of required medical record documentation and coding to ensure adherence with NCQA HEDIS and CMS Medicare Stars guidelines.
- Act as a liaison between internal departments on regulatory data validation audits (including Primary Source Validation, Prospective Medical Record Review and Retrospective (Hybrid) Medical Record Review.).
- Perform root cause analysis to identify issues that may contribute to medical record documentation and coding.
- Perform internal and external coding quality reviews to validate correct medical record documentation and coding.
- Other duties as Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.
QUALIFICATIONS:
Education & Prior Related Experience:
- Are a Licensed Registered Nurse (RN) or License Practical Nurse (LPN).
- Have a minimum of five (5) years combined experience performing NCQA, Health Effectiveness Data and Information Set (HEDIS) and CMS Medicare Star measure medical record and coding review AND conducting documentation and coding.
- Have experience with Microsoft Office Suite (Word, Excel, Outlook, and Internet Explorer) and Adobe Acrobat, including comfort with pivot tables at a minimum. Experience with SharePoint, Confluence, and Smartsheet is advantageous.
- Have bachelor’s degree in nursing or an equivalent combination of education and highly relevant experience preferred.
- Have knowledge and experience with NLP, computer assisted medical record review and coding applications (preferred).
- Have an applied understanding of principles of reimbursement-based CMS Medicare Stars and State Value Base program experience preferred.
Employment Eligibility:
- Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
- Complete and successfully pass a criminal background check.
Knowledge, Skills, and Abilities:
- Knowledge of acceptable medical record and coding standards and criteria in the context of NCQA HEDIS Technical Specification and Medicare Part C & D Star Technical Notes.
- Strong written and verbal communication
- Strong organizational, time management skills, and prioritization of work.
- Ability to design and update provider feedback report.
- Strong analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.
- Demonstrates professional courtesy to others and ability to maintain confidentiality.
To apply, please visit: https://www.chpw.org/contact-us/chpw-careers/
We're committed to our employees and their family, which is why we offer benefits that, makes a difference in their lives. Paid time off, tuition reimbursement, community service hours, and transportation perks are just a few of the offerings of our comprehensive and competitive benefits program.
Community Health Plan of Washington is an Equal Opportunity Employer with a diverse workforce!
Headquarters: 1111 3rd Avenue, Suite 400 Seattle, WA 98101