Responsibilities
- Medical Record Review & Abstraction: Access and review electronic medical records (EMR) and paper charts across diverse provider networks to extract documented clinical data required for NCQA HEDIS measures.
- Measure Validation & Data Integrity: Cross-reference and validate abstracted clinical information against standard NCQA HEDIS technical specifications to ensure complete data accuracy.
- Data Entry & Documentation: Accurately enter and catalog validated abstraction records into internal quality databases and specialized HEDIS software systems.
- Quality Assurance & IRR: Actively participate in Inter-Rater Reliability (IRR) testing and internal audits to maintain high consistency and quality control thresholds.
- Provider Outreach: Coordinate professional outreach to provider offices, clinical clinics, and health systems to request and retrieve missing or incomplete chart documentation.
- Compliance & Data Privacy: Adhere strictly to all HIPAA standards, state and federal regulations, and organizational security policies regarding Protected Health Information (PHI).
- Escalations & Reporting: Identify, track, and escalate missing documentation, charting anomalies, or systematic data discrepancies to Quality Improvement leadership.
Required Skills
- Experience: Minimum of 1 to 2+ years of direct, hands-on experience performing HEDIS chart abstraction, medical record auditing, or clinical quality measurement within a health plan, managed care, or clinical audit setting.
- Technical Skills:
- Proven proficiency navigating major EMR platforms (e.g., Epic, Cerner, Allscripts).
- Hands-on experience utilizing recognized HEDIS abstraction platforms (e.g., Cotiviti, Inovalon, Inovalon QSI).
- Coding & Standards Knowledge: Strong working knowledge of NCQA HEDIS specifications, medical terminology, and standard diagnostic/procedural coding sets (ICD-10, CPT, HCPCS).
Preferred Skills
- Preferred Certifications & Licensure: Active licensure or credentials strongly preferred:
- Registered Nurse (RN) or Licensed Vocational Nurse (LVN/LPN)
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT)
- Certified Professional in Healthcare Quality (CPHQ)
- Certified Professional Coder (CPC)
- Core Competencies: Exceptional analytical ability, acute attention to detail, strong organizational habits, and the discipline to work independently under strict seasonal deadlines.
Schedule/Shift
Standard business hours: 8:30am - 5:30pm Mon-Fri
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.