Job Description
The HEDIS and Risk Adjustment Nurse Practitioner performs functions that are both clinical and administrative. The patient care responsibilities are primarily telephonic and the administrative is primarily reviewing records and charts. The HEDIS and Risk Adjustment Nurse Practitioner must be a licensed and credentialed provider. This NP must have excellent clinical skills in order to analyze medical information, consider differential diagnoses and suggest diagnoses that are applicable to patients. The HEDIS and Risk Adjustment NP is also detailed in obtaining and reviewing the applicable medical records and clinical criteria. This employee should behave in a professional manner when interfacing with Medical Directors, physicians, office staff and other internal and external customers.
Thoroughly, accurately and timely review a patient’s medical records to flag diagnoses and to consider suspected diagnoses for the patient’s physician to consider and document, if applicable.
2. Inputting suggested diagnoses into databases in a prompt and timely manner.
3. Highlight needed quality measures as outlined by HEDIS for STAR/AMP. If a measure has been completed then to notify the STAR/AMP team to update the database.
4. Review and complete post discharge medication reconciliations for hospitalized patients.
5. Contact patients who were recently evaluated in an emergency room and document progress note.
6. Reach out to patients who have uncontrolled blood pressure to discuss medication management, medication adherence, disease education. Will also potentially provide medication recommendations to patient’s primary care provider.
7. Reach out to patients who have uncontrolled diabetes to discuss medication management, medication adherence, disease education. Will also potentially provide medication recommendations to patient’s primary care provider.
8. Review lab and radiology results ordered by Medical Director. This includes, but is not limited to, Hgb A1c, kidney evaluation tests, FIT tests, Cologuard results and Mammogram results.
9. Review medical records of patients with cancer to determine if patients have metastatic cancer and to flag appropriate codes for metastatic cancer.
10. Review medical records of patients who are on dialysis to ensure providers have identified and addressed all of the chronic conditions for each patient.
11. Interface with physicians, vendors, members, and internal staff telephonically or in person to obtain data.
12. Provide education in regards to Risk Adjustment and HEDIS to office staff and providers.
13. Assist the provider and provide feedback to the staff/provider on whether meeting CMS’s documentation requirements.
14. Remain updated on CMS’ Risk Adjustment program, medical knowledge and NCQA HEDIS Technical Specifications as it applies to the Risk Adjustment and HEDIS programs.
15. Interface with administrative assistant to track progress and production.
16. Interface with the coding department to ensure accurate documentation by the physician and receipt of needed charts.
17. Filing, faxing, copying and scanning of files, as needed.
18. Strive to meet personal, departmental and organizational goals and targets.
19. Ability to manage a heavy workload with frequent interruptions and changing priorities in a fast paced environment.
20. Completes assignments within specified time lines.
21. Able to work well in a team environment on special projects.
22. Skill in working independently, but with supervision.
23. Prepares and maintains records and files that are organized, thorough and readily accessible.
24. Attend regular team meetings and report findings of data collection and projects.
25. When identifies a problem, informs supervisor in a timely manner so the problem can be corrected.
26. Transmits ideas and information in a clear and concise manner.
27. Assist supervisor with special duties/projects.
28. All other duties as directed by management.
The pay range for this position at commencement of employment is expected to be between $130,000 - $150,000 DOEhowever, base pay offered may vary depending on multiple individualized factors, including market location, job related knowledge, licensure, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside
Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
Full Time Position Benefits:
The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.
Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.
Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.
Requirements
1. Credentialed and Licensed Nurse Practitioner.
2. Minimum of five years experience in clinical setting as either Family Practice, Internal Medicine.
3. Familiarity with managed care, commercial and point of service medical care preferred.
4. Computer literate with knowledge and experience with specific software such as Word, Excel, Access.
C. Organizational