Job Description

Job Title: Clinical Quality Reviewer

Location: Downtown Manhattan

Position Overview: A Hybrid The Clinical Quality Reviewer is responsible for assessing and auditing medical charts to ensure compliance with HEDIS, QARR , Medicare Advantage Star measures, and quality improvement activities. They will also play a role in supporting and training physicians on proper coding and medical record documentation. Additionally, the role may involve foreign language skills as a plus and participating in member outreach and education to ensure appropriate services.

Key Responsibilities:

Audit medical records for compliance with clinical measures and quality improvement standards.

Maintain knowledge of medical record review and EMR systems.

Distribute record requests and schedule appointments with providers.

Perform clinical audits to measure compliance and effectiveness of quality improvement initiatives.

Identify and report variations from standards of care and design interventions for improvement.

Enter clinical quality findings accurately and in a timely manner.

Assist in quality improvement activities and provide educational support to physicians and staff.

Facilitate the retrieval of medical record documentation.

Participate in the annual HEDIS and QARR hybrid medical record review project.

Perform other duties as assigned.

Required Qualifications:

Clinical background (e.g., Health Educator, RN, LPN, LMSW, LCSW, or Foreign Medical Graduate) with a minimum of three years relevant work experience.

Experience with medical record review in a managed care or health plan setting.

3-5 years of experience in Quality Improvement in a healthcare or managed care setting.

Knowledge of HEDIS and QARR specifications.

Experience with EMR systems (e.g., EPIC, Quadramed).

Proficiency in Microsoft Office applications.

Knowledge of ICD-10 and CPT codes is preferred.

Strong written and verbal communication skills.

Ability to read and interpret medical records and work both independently and in a team.

Professional Competencies:

Integrity and Trust

Customer Focus

Functional/Technical skills

Written/Oral Communication

Fluency in a foreign language is a plus, spanish language perfered

Job Tags

Work experience placement,

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