HEDIS Reviewer

Job Description - HEDIS Reviewer

Position Summary

Eclat Health Solutions is seeking experienced HEDIS Reviewers to support a large-scale validation initiative for our AI-powered clinical abstraction platform. In this role, you will review and validate HEDIS-related CPT, HCPCS, LOINC, and RxNorm abstractions generated by a Large Language Model (LLM), ensuring the accuracy, completeness, and clinical integrity of the data.

This position requires strong analytical skills, knowledge of HEDIS measures, and experience reviewing outpatient medical records to validate qualifying clinical events and supporting documentation.

Key Responsibilities

Review medical records to validate AI-generated HEDIS abstractions. Verify supporting documentation for CPT, HCPCS, LOINC, and RxNorm codes. Identify false positives, false negatives, and abstraction discrepancies. Validate qualifying clinical evidence in accordance with NCQA and client guidelines. Document findings using standardized review templates. Escalate complex or ambiguous cases to Quality Leadership. Participate in training and calibration sessions to ensure reviewer consistency. Meet established productivity, quality, and turnaround time expectations.

Minimum Qualifications

Candidates must meet one of the following qualifications: Clinical Background • Registered Nurse (RN), Physician (MD/DO), MBBS graduate, or other licensed clinical professional • Minimum of 2 years of HEDIS abstraction, quality measure review, or medical record review experience

OR

Coding Background

Minimum of 3 years of Professional Fee (Profee) outpatient coding or CPT/HCPCS abstraction experience • CPC certification preferred (AAPC) or equivalent coding credential • Experience reviewing outpatient physician documentation

Preferred Qualifications • HEDIS abstraction experience • Professional Fee (Profee) coding experience • CPT and HCPCS abstraction experience • Quality assurance or coding audit experience • Knowledge of NCQA HEDIS specifications • Knowledge of CMS coding and payer guidelines • Experience reviewing outpatient physician, ambulatory, or clinic documentation • Strong analytical, critical thinking, and written communication skills • Experience working with AI-assisted clinical abstraction or coding tools is a plus

Project Expectations • Review HEDIS measures and validate associated CPT, HCPCS, LOINC, and RxNorm abstractions. • Validate supporting clinical documentation and identify abstraction opportunities. • Participate in ongoing calibration and quality review sessions. • Meet established productivity and quality expectations throughout the project.

Ideal Candidate

The ideal candidate has experience performing HEDIS abstraction, outpatient coding, or clinical quality review and is comfortable navigating complex medical records to validate qualifying clinical evidence. They demonstrate excellent attention to detail, sound clinical or coding judgment, and the ability to consistently evaluate AI-generated abstractions against established HEDIS, coding, and documentation guidelines.

Interested candidate's can share the CV to the below mentioned mail id

[email removed]