Clinical Data ReviewerJob Location US-IL-ChicagoJob ID 2018-6629Category Quality ImprovementBusiness Line MHP Illinois Overview Who we are: Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry. We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide. Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities. A Day in the Life of a Clinical Data Reviewer: This position is responsible for ongoing medical record data over-reads and review, training for HEDIS and state-specific performance measures, validation of HEDIS records and exclusions, and data entry as directed by the Manager of Quality Data Abstraction. The Clinical Data Reviewer is also a consultant for the abstraction team and may serve as content expert for provider education initiatives with clinical and documentation scope. This position is responsible for identifying medical record types utilized by internal operational departments that contain applicable Quality Improvement data to be abstracted. Responsibilities Follows established procedures and creates new policies/procedures for requesting medical records, abstracting data and entering dataSupports the annual Healthcare Effectiveness Data and Information Set (HEDIS) medical record review project by performing reviews and over-reads of abstraction data collected by Abstraction Team and/or from faxed records received from provider officesReviews potential data exclusions and requests additional information Tracks and trends exclusions identified to update training materials and initiate abstraction initiatives in collaboration with the Manager of Quality Data AbstractionResearches best practices for clinical documentation and data sources to disseminate and educate abstraction teamAssists with oversight of internal medical record databases, ensure appropriate training of all individuals entering clinical data into medical record databases, and monitor quality assurance processesEnsures that all information is maintained in a safe, organized and confidential mannerProvides feedback to Manager regarding the abstraction over-read process, potential educational or organizational resources needed to complete abstractions accurately and other concerns related to chart abstraction Meets or exceeds established inter-rater reliability audit standardsWorks collaboratively to implement strategies and processes for educating practitioners on effective HEDIS medical record documentation and claims coding for improvements in HEDIS administrative and hybrid ratesMaintains relationships with subject matter experts (SMEs), Quality Improvement team stakeholders, and data abstraction staff to facilitate and streamline medical record abstracting process Reviews withhold programs and other requirements to identify areas of opportunity, barriers, and points of clarification to ensure appropriate data is abstracted and excludedPerforms other duties as assigned Qualifications What you can bring to Meridian:Current LPN or RN Licensure or Certified Medical Assistant certification to practice in the State is required; LPN or RN Licensure is preferredBachelors degree or Fellow designation from the Academy for Healthcare Management (AHM) is preferredAt least two years of relevant clinical experience involving medical record documentation or medical claims experience preferredPrior HEDIS clinical field experience and HEDIS certified software experience preferredPrevious experience in managed health care and Medicare/Medicaid programs is preferredDemonstrated success in data entry accuracy, integrity, review, and documentationWell versed in various electronic medical record (EMR) systems and navigationLeadership experience preferredDetailed knowledge of computers/systems including word processing and Excel spreadsheetsStrong knowledge base of HEDIS Technical StandardsKnowledge of claims and coding setsKnowledge of MS Project softwareStrong knowledge base of HEDIS Technical Standards and HEDIS Compliance Audit Standards preferredExcellent written, verbal, presentation skills and inter-personal skills Strong computer skills, including Microsoft Office (Word, Excel, PowerPoint) Strong analytical and data interpretation skillsStrong organizational skillsAbility to exercise good judgment and maintain confidentialityAbility to coordinate multiple competing, complex tasks What Meridian can offer you:Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.Opportunity to work with the industrys leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.Meridian offers 401k matching that is above the national average.Full-time Meridian employees are eligible for tuition reimbursement towards Bachelors or Masters degrees.Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian. Equal Opportunity Employer