Remote Lead HEDIS Data Reviewer

AmeriHealth Caritas

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Newtown Square, Pennsylvania, 19073
Category Medical Management and Quality
Job Id 31540

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation’s leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at


Under the direction of the Director of Medical Record Review Operations the Lead HEDIS Data Reviewer is responsible for duties including but not limited to the following:

  • Responsible for the coordination and maintenance of the Medical Record Review workflow process for assigned plans and assigned administrative staff.
  • Ensures compliance with Medical Record Review workflow process by assuring that their designated staff performs and applies structured auditing abstraction criteria to medical records to determine compliance to NCQA HEDIS specification and data collection activities as designated by the health plan with an adherence to plan timelines.
  • Tracking of large volume providers for onsite medical record reviews and other special handling requirements
  • Coordination with each designated health plan for state and compliance approval for HEDIS letters for distribution.
  • Work with Plans to ensure accuracy and completion of General Information, Appendix 1 and Section 4 of Roadmap,;
  • In conjunction with MRR Ops Manager review with Plans auditor log/issues/concerns and update as needed.;
  • Prepare and package records for CSV, PSV, and MRRV
  • Attend assigned plan meetings and work in conjunction with MRR Ops Manager for plan meeting minutes;
  • Review assigned plan and department meeting minutes with follow-up on action items and issues.
  • Locate and review all assigned provider submitted medical records and perform abstraction according to NCQA HEDIS specifications.
  • Utilizes various software applications to support HEDIS operations and accurately enters the results of chart audits into the database.
  • Provide clinical and administrative support to stakeholders and plan partners.
  • Abstract a minimum of chases/charts according to policy while maintaining an abstraction proficiency rate of 98% by correctly reading, interpreting, and abstracting various components of the medical record such as notes, consultations, mediation, treatment, health history, interval history, and past history.
  • Collaborate and work on designated projects assigned and deemed as necessary.
  • Attend and participate in internal HEDIS and vendor meetings.
  • Support operations for the Enterprise HEDIS medical record collection projects.
  • Ability to organize and work effectively in administration required.
  • Ability to work within a team concept.
  • Managerial skills and abilities such as team building, HR management including conflict management, performance appraisal, coaching, and utilization management techniques required.
  • Perform, summarize and report on over-read and inter-rater reliability audit statistics in aggregate and by individual abstractor.
  • Collaborate with the Director of Medical Record Review Operations to select, monitor and provide vendor oversight for timeliness and quality standards.


  • Bachelor’s Degree preferred or equivalent experience.
  • 3-5 years experience working with HEDIS data including chart review/collection.
  • Proven leadership skills and ability to direct others without formal authority.
  • Proven ability to influence at all levels.
  • In-depth understanding of current HEDIS Technical Specifications.
  • QRS or STARS experience
  • LPN, CNS, APRN or RN preferred. Medical Record Professionals and Coders with demonstrated expertise in managing a HEDIS Project will be considered
  • Knowledge of medical terminology and basic charting to include diabetic labs, HPV testing, preventive health screenings, immunization and well care terminology.;
  • Knowledgeable about performance improvement systems, principles, and designs.
  • Project Management experience.
  • Experience in Excel, Word, Power Point and Outlook.
  • Strong written and oral communication skills, critical thinking skills, proficiency in Microsoft Office products, strong organizational skills.
  • Experience with, and wiliness to learn any Medical Record Abstraction Tool.
  • Experience in the Pediatric, Maternity, Diabetic or Provider Office Setting.
  • Knowledgeable in the HEDIS audit process (PSV, CSV, MRRV).
  • Experience with non-HEDIS State Audits.
  • Familiar with the Cancer Registry.
  • Familiar with Bright Futures.;
  • Ability to think and work effectively under pressure.
  • Ability to function effectively within multidisciplinary teams.
  • Ability to accurately complete tasks within established times.;
  • Ability to effectively prioritize multiple tasks and deadlines.

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.