Clinical Review Specialist (Per Diem)

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Responsible for quality management clinical review activities including but not limited to medical record reviews for the annual HEDIS project and quality of care issues. Works collaboratively with Provider Relations, Business Development, and external vendors to ensure compliance with medical record and incentive requirements.

• RN required. Bachelors degree in healthcare, business, finance, or other related analytical fields
• Minimum 3-5 years' experience in the healthcare or managed care industry, or related field
• Experience and knowledge with HEDIS, CAHPS, CMS Star Ratings, and Accreditation process

• Experience with project management skills, planning, and budgeting

• Ability to work in a fast-paced and dynamic environment with minimal supervision and direction and to constantly redefine responsibilities to meet business needs

• Acts with a sense of urgency

• Computer literacy and experience with word processing, spreadsheets, database programs and good typing skills

• Knowledge, understanding, and accurate interpretation of product line related specifications, methodologies, and processes

• Excellent interpersonal skills to manage, motivate, and influence departmental staff in successfully accomplishing of their duties

• Ability to demonstrate effective critical thinking and problem solving skills