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Clinical Quality Reviewer

Job Ref: 43241
Category: Utilization Review and Case Management
Department: QUALITY MANAGEMENT
Location: New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $80,000.00
Salary Range: $80,000.00 - $88,000.00

Marketing Statement

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview
The primary function of the Clinical Quality Reviewer is to assess and audit medical charts for compliance with a focus on HEDIS, QARR, Medicare Advantage Star measures and quality improvement activities. This position will assist in the development and participate in the implementation of initiatives across a broad array of clinical measures and health improvement activities. Quality audit findings from this position will contribute to the support and training of physicians on proper coding and medical record documentation practices to support improvement in quality metrics. As a result, this role will be required to conduct regular internal provider audits and then document, summarize and report findings. Additionally, participation in the annual HEDIS and QARR hybrid medical record review project will be required. This role may also participate in member outreach and education as needed to ensure members receive appropriate services.

Job Description

  • Maintain knowledge of medical record review and EMR systems. 
  • Maintain up-to-date knowledge of HEDIS, QARR and Star specifications
  • Distribute requests for records and schedules appointments with provider offices to ensure timely completion of duties to meet internal and regulatory standards and requirements.
  • Perform clinical audits via EMR, in-house paper medical records, on-site provider visits to measure compliance with preventive health guidelines and to measure effectiveness of quality improvement initiatives.
  •  Identify, track and report variation from standards of care by audit of core operations, patient care processes and medical record documentation.  Designs interventions to drive improvement and minimize variation from standards of care. 
  • Data enter accurate and timely clinical quality findings in the appropriate system(s) in accordance with established documentation standards for MetroPlus Health Plan to ensure integrity of member services provided over the continuum of care and over time. 
  • Assist in implementation of quality improvement activities as directed by Quality Management programming needs. Support interdepartmental and internal teams focused on process improvement projects and outcomes.
  • Provide educational support to physicians and staff to ensure process improvement and increase member satisfaction, member retention, continuity of care and drive HEDIS and QARR improvement activities.
  • Facilitate retrieval of medical record documentation and work with provider group(s) and in-field navigators to retrieve electronic and paper records that supports HEDIS/QARR. 
  • Records findings of patient encounters to include patient identifiers, relevant information and results in database.  
  • Participate in the annual HEDIS and QARR hybrid medical record review project:
    • Work with provider offices to facilitate request and review of charts
    • Supports temporary staff in the review of medical records (electronic and paper-based)
    • Serve as a final reviewer of HEDIS and QARR records
  • Other duties as assigned by Quality Review Lead or QM Operations Director.

Minimum Qualifications

  • Clinical background:  Health Educator, RN, LPN, RN, LMSW or LCSW, Foreign Medical Graduate (FMG) with a minimum of three years relevant work experience.
  • Experience with medical record review working on HEDIS/QARR in a managed care or health plan setting.
  • 3 – 5 years in Quality Improvement in a health care and/or Managed Care setting strongly preferred.
  • Ability to travel within the MetroPlus service area.
  • Knowledge of HEDIS and QARR specifications.
  • Experience using EMR systems, e.g. EPIC, Quadramed.
  • Proficient in Microsoft Office applications including Word, Excel, PowerPoint and Access.
  • Knowledge of ICD-10 and CPT codes preferred.
  • Strong written and verbal presentation.
  • Ability to proficiently read and interpret medical records; Ability to measure compliance and identify deficiencies in chart documentation against standards.
  • Ability to work in a team setting and independently prioritize projects and assignments.

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication

How To Apply

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:


MetroPlus Health Plan
Human Resources Department
160 Water Street 8th Floor
New York, NY 10038
Attn: Recruitment Unit