Hedis Clinical Reviewer I (Rochester) -007402

Excellus Bluecross Blueshield Rochester , NY 14618

Posted 2 months ago


In constant pursuit of improving quality outcomes for the Health Plan, this position exists to retrieve and abstract data from medical records based upon an established set of guidelines. In addition, the second level of this job is responsible for auditing the retrieval and abstraction results.

This is a seasonal role in which employees work the months of January through April. The daily schedule is flexible based upon supervisor approval though employees will be expected to work 30 - 40 hours per week.

NOTE: This is a work-from-home position that requires the incumbent to have high-speed internet access in their home office.

Essential Responsibilities/Accountabilities:

All Levels:

Level I:

  • Conducts medical record review based upon standards outlined in department training manual

  • Retrieves, abstracts and transmits pertinent medical record information as it relates to regulatory requirements, including but not limited to, HEDIS/QARR, CMS and DOH.

  • Travels to/from provider offices or other health facilities to complete reviews, as necessary.

  • Performs outreach to members and/or providers to facilitate appropriate preventive and chronic illness care, as necessary.

  • Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.

  • Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

  • Regular and reliable attendance is expected and required.

  • Performs other functions as assigned by management.

Level II (in addition to Level I essential responsibilities/accountabilities):

  • Audits the retrieval and abstraction efforts of Level I teammates.

  • Accompanies Level I team members on provider/facility visits for training and/or oversight purposes.

Minimum Qualifications:


We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels:

Level I:

  • RN with current New York State License or Certified Professional Coder (CPC) with a minimum of two years of extensive medical record review experience

  • Electronic Medical Record/Electronic Health Record experience preferred.

  • HEDIS experience preferred.

  • Home office set up with high-speed internet service.

  • Microsoft office product experience preferred.

  • Capable of day travel.

  • Self-motivated and capable of working independently while meeting deadlines. Ability to multi-task and independently troubleshoot problems.

  • Must be available and accessible during business hours.

Level II (in addition to Level I minimum qualifications):

  • A minimum of 3 years progressive HEDIS experience as per diem clinical reviewer.

  • Recognized as a HEDIS, QARR, and QRS hybrid subject matter expert.

  • Experience interacting with providers, external regulators and Certified NCQA auditors.

Physical Requirements:

  • Ability to independently travel to provider offices or facilities to complete reviews.

The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.


Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

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Hedis Clinical Reviewer I (Rochester) -007402

Excellus Bluecross Blueshield