Job Description

HEDIS Data Reviewer

The HEDIS Data Reviewer is responsible for performing high-volume, detail-oriented medical record abstraction, overread, and quality review activities in support of annual Healthcare Effectiveness Data and Information Set (HEDIS), State EQRO, and other quality reporting initiatives. This role requires a highly productive, accurate, accountable, and self-motivated individual who can work independently in a fast-paced, deadline-driven environment while maintaining strong attention to detail, professional communication, and a solutions-focused approach to changing priorities.

Responsibilities:

• Under the direction of the Manager of Medical Record Review Operations, the HEDIS Data Reviewer performs medical record abstraction, overread, collection support, and related project activities in support of quality reporting requirements. Duties include, but are not limited to, the following:
• Perform medical record abstraction including data entry into tool, overread, and quality review using applicable HEDIS, State, and project-specific technical specifications.
• Apply structured abstraction and auditing criteria to determine whether medical record documentation supports compliance with measure requirements.
• Accurately enter abstraction, audit, and review results into designated software applications and databases within established timelines.
• Develop and maintain working knowledge of mandated HEDIS, State, and project-specific performance measures, including measure requirements, exclusions, numerator criteria, documentation standards, and audit expectations.
• Complete assigned abstraction and overread work in live software environments while providing clear feedback when documentation does not meet HEDIS, State, or project-specific criteria.
• Coordinate and support medical record identification, collection, retrieval, review, and follow-up activities as assigned.
• Consistently meet or exceed established productivity expectations while maintaining required accuracy, quality, and turnaround time standards.
• Maintain an abstraction proficiency of 98% or higher by accurately reading, interpreting, and abstracting documentation from medical record components such as progress notes, consultations, medication forms, treatment plans, health histories, interval histories, and past medical histories.
• Assist with medical record collection activities, including provider outreach, phone calls, fax or letter follow-up, and chart retrieval requests as assigned.
• Manage multiple project assignments, shifting priorities, and competing deadlines while maintaining accuracy, productivity, and professional communication.
• Proactively identify questions, documentation gaps, workflow barriers, or potential quality concerns and escalate them timely through appropriate channels.
• Demonstrate accountability for assigned work, including timely completion, accurate documentation, follow-through on feedback, and appropriate escalation of issues before delays occur.
• Adapt to changing project needs, measure updates, workflow changes, tool enhancements, and operational priorities in a professional and solutions-focused manner.
• Complete additional designated projects, special assignments, testing, training, or operational support activities as assigned.

Requirement:

• Three to five years of experience working with HEDIS data, medical record review, chart abstraction, chart collection, quality reporting, QRS, STARs, or similar healthcare quality initiatives preferred.
• Knowledge of medical terminology and basic charting, including diabetic labs, HPV testing, preventive health screenings, immunizations, well-care terminology, maternity care, pediatric care, adult care, and related clinical documentation.
• Understanding of current HEDIS Technical Specifications and ability to apply measure guidance consistently.
• Knowledge of HEDIS audit processes, including PSV, CSV, MRRV, and audit-ready documentation expectations preferred.
• Proficiency in Microsoft Excel, Word, PowerPoint, Outlook, OneNote, Teams, and other software applications used to support medical record review operations.
• Experience using medical record abstraction tools and willingness to learn new abstraction platforms, retrieval tools, databases, and workflow systems.
• Experience in pediatric, maternity, diabetic, preventive care, provider office, health plan, medical record, coding, or quality review settings preferred.
• Familiarity with Cancer Registry documentation and Bright Futures guidance preferred.
• Strong written and verbal communication skills, critical thinking skills, organizational skills, and ability to document and communicate questions or barriers clearly.
• Ability to work independently, manage time effectively, remain organized, and meet deadlines in a high-volume production environment.
• Strong attention to detail with demonstrated ability to maintain accuracy while reviewing complex or lengthy medical record documentation.
• Self-motivated with the ability to take initiative, identify next steps, follow through on assignments, and ask appropriate questions without repeated prompting.
• Receptive to feedback and able to consistently apply coaching, audit findings, updated guidance, and process changes to future work.
• Professional, dependable, adaptable, and solutions-focused when responding to workflow changes, competing priorities, feedback, or project challenges.

Education:

• High school diploma or GED required.
• Bachelor’s degree preferred.
• LPN, CNS, APRN, or RN preferred. Medical record professionals and coders with demonstrated expertise in HEDIS abstraction will also be considered.

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