The Clinical Medical Review Specialist (a professional with clinical experience) will report to the Clinical Support Supervisor HEDIS and be part of the Quality Team. The main duties include chart retrieval, using proprietary tools and software to conduct thorough medical record reviews in line with NCQA specifications, retrieval follow-up, and escalating issues as needed. Main duties will be assigned according to experience, knowledge, skills, and abilities. This role requires extensive knowledge of HEDIS measures to accurately and expediently abstract medical records, all while adhering to HIPAA Privacy and Security standards. Additional tasks involve helping with EMR Medical Record Retrieval for HEDIS, contacting provider offices to request or validate facility and provider contact information and record retrieval preference, and/or requesting medical records for the HEDIS project and supporting other needs within the Quality Department.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Bachelor's degree in Nursing, Associate's degree in Nursing, or Diploma in Nursing. In lieu of a degree, candidates must have 10 years of relevant HEDIS abstraction and/or overread experience in a payer, health insurance, or HEDIS vendor environment.
Education Details: Registered Health Information Associate/Registered Health Information Technician, Nursing, or a related clinical or healthcare field. Candidates qualifying in lieu of a degree must have 10 years of recent, directly relevant HEDIS medical record abstraction and/or overread experience within a payer, health insurance, or HEDIS vendor setting, including demonstrated knowledge of NCQA HEDIS specifications and abstraction platform workflows.
Experience: 3 years of clinical experience and 5 years of HEDIS experience.
Candidate Profile: We are seeking a qualified RN or LPN with experience supporting HEDIS reporting and abstraction processes in a payer, health insurance, or HEDIS vendor environment. The ideal candidate will understand NCQA healthcare quality metrics and have a proven ability to accurately abstract, interpret, and document medical record data for HEDIS gap closure.
Technical Skills and Tools: Candidates must be detail-oriented, able to work independently, and maintain a high level of accuracy. Required technical skills include proficiency with Microsoft Office, including Excel, Word, PowerPoint, Microsoft Teams, and Outlook. Experience retrieving medical records from EMR platforms such as Epic, eClinicalWorks, Athena, Cerner, Allscripts, and Tebra is essential. HEDIS overread experience with a health plan or HEDIS vendor is preferred.
Location and Training Expectations: Ideal candidates reside in or near MD, DC, VA, PA, or DE. Applicants must attend in-person training at CareFirst's Merriweather office in December 2026, with exact dates to be provided.
Candidates are responsible for any travel costs associated with attending this training.
In Lieu of Education
10 years of recent HEDIS abstractions / overreads experience in the payer/health insurance side of HEDIS or with a HEDIS vendor (ex. Cotiviti, Inovalon, Reveleer)
Preferred Qualifications
Bachelor's degree in Nursing, Associates Degree in Nursing, Diploma in Nursing
At least two recent consecutive HEDIS seasons with the same company.
Required Skills
1. Current knowledge of clinical practices related to HEDIS and medical record review.
2. Strong organizational skills, including the ability to prioritize responsibilities, maintain attention to detail, and shift tasks as needed.
3. Experience using Microsoft Office applications, including Excel, Word, and PowerPoint, as well as web-based technology.
4. Excellent verbal and written communication skills.
5. Strong interpersonal skills, with the ability to work independently and as part of a team.
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