HEDIS Abstractor

Essential Duties and Responsibilities:

• Reviews medical records to abstract data elements required for HEDIS reporting, focusing on both hybrid and administrative measures.
• Applies knowledge of NCQA HEDIS technical specifications to determine measure compliance and exclusion criteria.
• Validates relevant ICD-10-CM, CPT, and HCPCS codes to support quality measure documentation.
• Navigates multiple EMR systems to locate and interpret clinical information (e.g., progress notes, lab results, specialist reports).
• Ensures abstraction accuracy by adhering to inter-rater reliability standards and internal quality assurance benchmarks.
• Works closely with QA leads, clinical reviewers, and team leads to resolve discrepancies and clarify guidelines.
• Participates in pre-season and in-season training sessions to stay current on evolving HEDIS measure specifications.
• Maintains detailed documentation of abstraction logic and rationale for audit trail and client reference.
• Contributes to continuous process improvement by identifying documentation gaps, workflow inefficiencies, or system issues.
• Maintains strict compliance with HIPAA and organizational privacy/security standards when handling patient data.

Qualifications:

• Registered Nurse (PH RN)
• HEDIS-trained or minimum of 2 years of experience in HEDIS coding (required for Associate level)
• Active coding certification (e.g., CPC) required for Associate level
• Coding certification not required for entry-level applicants
• HEDIS experience not required for entry-level applicants