Nurse HEDIS Reviewer
About the job
- A bachelor's degree in nursing is required.
- An active and unrestricted nursing license is required.
- Five or more years of experience in the health care industry, in HEDIS and/or quality improvement, is required.
- Experience in a managed care health services environment is required.
- NCQA and HEDIS experience is required.
- The ability to navigate multiple electronic medical record and health plan applications is required.
- Intermediate proficiency in Microsoft Word, Excel, and Adobe is required.
- Strong organization and attention to detail are required.
- Perform clinical record reviews, data validations, and overreads to ensure accuracy and compliance with HEDIS measures.
- Develop reports to identify HEDIS care gaps and trends, and work closely with providers to ensure necessary services are provided and documented according to HEDIS requirements.
- Conduct analysis to identify patterns, root causes, and opportunities for process and performance improvement.
- Support Health Plan Quality programs and reporting for regulatory requirements, including CMS, DHA, and NCQA.
- Prioritize reports according to business needs, regulatory requirements, urgency, and other key business factors.
- Assist in coordinating outreach efforts as needed to request, collect, and secure clinical documentation from individual providers or provider groups according to individual HEDIS measure specifications.
- Identify, collect, document, and store HEDIS data in accordance with standard operating procedures and HEDIS technical specifications.
- Apply clinical judgment to validate diagnoses, procedures, exclusions, and documentation elements.
- Educate non-clinical staff on HEDIS requirements and the clinical relevance of data.
- Collaborate with physicians, office staff, and care teams to obtain medical records, support HEDIS quality initiatives, provide education on HEDIS measure requirements, documentation standards, and coding opportunities, and facilitate timely gap-closure activities.
- Maintain NCQA and other training requirements and meet productivity standards as directed by the HEDIS supervisor.
- Perform other duties and responsibilities as assigned.
- Certified Coder certification is preferred.
About the company
Martin's Point Health Care is a not-for-profit health care organization that provides medical services to individuals and families. Its offerings include a range of primary and specialty care delivered through clinics and care teams, with a focus on coordinated, accessible patient care and preventive services. The company reinvests profits back into the organization to improve care, expand community benefits, and keep services affordable. Unlike for-profit competitors, it emphasizes community health impact and long-term patient relationships, supported by a mission-driven, member- or patient-centered approach. The goal is to improve the health of the communities it serves by delivering high-quality, affordable care and reinvesting earnings to enhance services and access.
Company Size
501-1,000
Company Stage
N/A
Total Funding
N/A
Headquarters
Portland, Oregon
Founded
1981
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Simplify's Take
What believers are saying
- New telehealth for urgent care and mental health expands low-friction utilization in 2026.
- Provider guidance on HEDIS, coding, and prior authorization signals active margin and quality defense.
- Martin's Point still accepts new patients across Southern Maine and New Hampshire, supporting growth.
What critics are saying
- InterMed drops Martin's Point Medicare Advantage in January 2027, threatening 4,500 members.
- DOJ settlement for 2016-2019 risk-adjustment fraud still damages trust and CMS scrutiny.
- TRICARE contract dependence creates existential exposure if Defense rebids or tightens terms.
What makes Martin's Point Health Care unique
- Nonprofit Maine anchor spanning care delivery, Medicare Advantage, and TRICARE Prime since 1858.
- Six Health Care Centers plus payer contracts create integrated referral, data, and retention loops.
- 2026 Medicare stars stayed competitive: HMO 4-star, Select LPPO 3.5-star.
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Benefits
- Professional Development Budget