- The Clinical Reviewer performs medical record reviews to determine the quality of care; identifies quality issues and assures compliance with medical record standards and regulatory mandates; works collaboratively with Fidelis Care New York providers and educates them on all aspects of medical record review criteria including QARR/HEDIS; conducts member and/or provider telephonic outreach when needed.
- Stays abreast to changes in Fidelis’ Performance Management measures and systems and changes in clinical guidelines.
- Perform reviews of medical records and standards; post completed review reports with the number of records reviewed and quality issues noted.
- Collaborate with providers and adhere to clinical standards of care to ensure appropriate outcomes; practice and adhere to departmental, state, and national guidelines.
- Educate providers on clinical guidelines and QARR/HEDIS measures.
- Communicate in an efficient, effective, and friendly manner with providers, internal, and external staff.
- Attend educational workshops; review professional publications; establishing personal networks; participate in professional societies to maintain professional and technical knowledge.
- Travel when required.
New York State RN or LPN License or FMG required. One year nursing experience, Clinical experience preferred. A minimum of one year of HEDIS/QARR Medical record review and audit experience, required. Proficiency in Microsoft Office: Excel, Word, Internet. Business Analysis Knowledge: Skilled to work in a fast-paced environment. Must have strong analytical and problem-solving skills. Ability to assess treatment needs and make recommendations that impact desired outcomes and quality of care. Customer Service: Skilled to communicate with all levels of management, internal and external customers. Ability to work well as a member of a team or alone. Effective Business Communication: Skilled in communicating with technical and business constituencies in writing effective business specifications and requirements. Requires proven ability to consistently meet and /or exceed goals. Must be capable of making commitments, setting priorities, and delivering results on time.
New York State RN or LPN License or FMG required. Must have own transportation and valid driver's license.
Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristics protected by applicable law.