“The Healthcare Effectiveness Data and Information Set (HEDIS) is one of health care’s most widely used performance improvement tools” according to their website www.NCQA.org. As such, there exists a large, somewhat transient, community in Healthcare from a variety of “HEDIS Angles.” These include payor executives who make the multi-million-dollar decisions to go ahead with their next seasons “self-audit,” all the way to the records retrieval staff who pursue records for HEDIS review. This article will discuss the “people dilemma” and solutions for staff search, recruitment, vetting, credentialing, and testing.

HEDIS Staff include:

This list and its associated job title is an outline only and does not represent the many other qualifications and possibilities.

Executives = (CEO, CFO, Rev. Cycle. Director, HIM Director, HEDIS Project Executive)

Directors = (RN, HEDIS Project Executives, Accountants, IT)

Managers = (RN, HEDIS Project Executives, Accountants, IT, clinical coders)

Leads = (RN, HEDIS Project Executives, Accountants, IT, clinical coders)

Project Managers = (RN, HEDIS Project Executives, Accountants, IT, clinical coders)

Abstractors = (RN, HEDIS Project Executives, Accountants, IT, clinical coders)

Researchers = (RN, HEDIS Project Executives, Accountants, IT, clinical coders)

Over Readers = (RN, HEDIS Project Executives, Accountants, IT, clinical coders)

Records Retrieval or Pursuit = (Reception, call center, administrative assistant, HIM specialist)

HEDIS Season

The NCQA defines the HEDIS season and for simplicity’s sake, let us say January to May each year is this season. The is the intense 4+ months by which all the “Measure Review” work is done. The reality is that the working season, is followed by the analysis season, which overlaps with the planning/recruitment season, which runs headlong into the next HEDIS season. This stress cycle has many components, but our focus will be on recruiting, vetting, and hiring HEDIS Staff for each season.

As the system above has a built-in model of temporary employment and at least half of the staff need a high skill level in terms of medical terminology, NCQA Measure Requirements, a working knowledge of medicine and its delivery systems, and much more, the recruitment, training, and hiring can be particularly challenging for payors.

HEDIS Seasonal Roles and Responsibilities (payer centric versus vendor centric)

  1. (payer) Executive plans, secures financials, and oversees the execution of the project.
  2. (payer) Director plans, does high level direction of staff and execution of steps for project completion.
  3. (payer) Manager plans, secures staff does high level direction of staff and executes plan to complete project. Managers manage timelines, milestones, and problem resolution daily as well as reporting both up and down the project ladder. This induvial may experience direct contact with staff.
  4. (Payer) Lead manages staff according to Managers direction. Lead will have and can expect daily interaction with staff. Lead should be incredibly strong in Human Resources and Project Management, as the daily responsibilities here are intense.
  5. (vendor) Pursuit retrieves records for review by abstractors, researchers, and over readers.
  6. (vendor) Abstractor are the skilled staff who retrieve pertinent data from the record as part of “Measure Review”..
  7. (vendor) Researcher are the skilled staff who find “further” or “potentially missed” opportunities in “Measure Review.”
  8. (vendor) Over Reader confirms the measure review by both researcher and abstractor for accuracy.

Let us review a few challenges about filling these HEDIS positions:

Executives (payer centric) – Most of the Executive positions associated with HEDIS will be a full time, well paid, benefited position, so your cost will be a factor for sure. Surprisingly, a number of these individuals have a rudimentary understanding of HEDIS. Our vetting process here must include a walkthrough of the candidate’s understanding of HEDIS and primarily its technical, financial, and Human Resource needs. This vetting should include credentialing, background checks, credit check, interview, group interview, physical, Covid vaccination review (vaccinated and boosted), and rudimentary HEDIS knowledge test as a baseline. The client is welcome to add testing and vetting from a lengthy list of available vetting tools. To be clear, an executive at this level may bring a whole distinct set of skills to the equation so limited HEDIS knowledge may be acceptable if say, they have strong skills in Project Management, Accounting, or other factors deemed critical.

Directors (payer centric) – Directors are generally full time, well paid, benefited position, so your cost will be a factor for sure. Here we have the “brains of the operation,” and these individuals often are the alpha and omega player in the entire operation. These individuals are very often planning, managing, assessing, reporting, and closing your project. This is often the make-or-break individual. As such, their vetting process needs to be extensive and their vetting process intense. Our vetting process here must include a walkthrough of the candidate’s understanding of HEDIS and primarily its technical, financial, and Human Resource needs. This vetting should include credentialing, background checks, credit check, interview, group interview, physical, Covid vaccination review (vaccinated and boosted), and rudimentary HEDIS knowledge test as a baseline. The client is welcome to add testing and vetting from an extensive list of available vetting tools. In addition, this induvial would ultimately be asked for a written and verbal walkthrough of a season’s business plan for achieving the goals set forth by administration.

Managers (payer centric) – Supplementing the Directors, this role tends to have a different feel than the previous two positions described above. This is because this role interacts with all the remaining positions and often daily. This individual really needs to have people skills, combined with good leadership qualities. Because milestones, timelines, goals are the pressure they get from the top executives, they must also do “real world” problem solving daily as it arises from the staff below them. This individual should be strong in their people and leadership skills. Our vetting process here must include a walkthrough of the candidate’s understanding of HEDIS and primarily its technical, financial, and Human Resource needs. This vetting should include credentialing, background checks, credit check, interview, group interview, physical, Covid vaccination review (vaccinated and boosted), and rudimentary HEDIS knowledge test as a baseline. In addition, we would recommend personality and critical thinking testing. These tests can be helpful in establishing “baseline” scores that are acceptable or not.

Leads (payer centric) – Supplementing managers, this position, more than any other, is the bridge between the client and the vendor. This position carries with it a lot of weight and responsibility in terms of projects goals, daily goals, and as the project nears the end, potentially hourly goals. This can be a high stress position as it involves answering to authority in your own shop, while managing attendance, training, skill assessment, workload assignment, HR issues, illness by staff, internal disruption, technical issues with software, HR issues, communication with the Project Manager and the list goes on and on. This vetting should include credentialing, background checks, credit check, interview, group interview, physical, Covid vaccination review (vaccinated and boosted), and rudimentary HEDIS knowledge test as a baseline. In addition, we would recommend personality and critical thinking testing. These tests can be helpful in establishing “baseline” scores that are acceptable or not.

Project Managers (vendor centric) – This position represents the vendor and serves as the “lead” on the vendor side. Like the Payer Centric Lead, this position is critical in this individual’s ability to flex and adjust on a daily and often hourly basis. In a perfect world, the Payer Centric Lead and the Vendor Centric Project Manager should be communicating often about the many details of Project Management, HR Issues, and the general “state of the project.” This vetting should include credentialing, background checks, credit check, interview, group interview, physical, Covid vaccination review (vaccinated and boosted), and rudimentary HEDIS knowledge test as a baseline. In addition, we would recommend personality and critical thinking testing. These tests can be helpful in proving “baseline” scores that are acceptable or not.

Abstractors (vendor centric) – This position is the obvious starting point for staffing agencies to describe why they are the better choice, but the positions described above this one is the foundation upon which this position is built. A great abstractor working in a poorly managed project is not likely to pull off miracles, in terms of making the project a success. Reverse that situation and instead you get a great abstractor with great organization and leadership, and you will find that you will have impressive results in terms of productivity and quality of results. No position deserves vetting and testing like this position. We will first describe vetting but focus on our conclusion about testing. This vetting should include credentialing, background checks, credit check, interview, group interview, physical, Covid vaccination review (vaccinated and boosted), and rudimentary HEDIS knowledge test as a baseline. In addition, we would recommend personality and critical thinking testing. These tests can be helpful in showing “baseline” scores that are acceptable or not. 

In addition, this testing should be extensive in terms of “measure testing,” HEDIS knowledge, software systems (earlier systems you have worked on), their ability to flex, their capacity to problem solve, and the overall state of their life, currently. This last part addresses the state of their world now. As the projects got a 4-month intensity we will spend a fair amount of time cutting potential project killers in the life of the abstractor such as:

  • Second job or school responsibilities
  • Caring for an elderly parent or other care assist dependency of any kind.
  • Scheduled vacations/time off
  • Willingness to “commit” to this project

To quantify this a bit more, the vendor pays for recruitment, vetting, credentialing, testing, and onboarding, and payroll. 

The client/payer pays for onboarding, tech set up, vendor invoices, training, and compliance. 

At the initiation of “Go Live” both parties have a lot invested both financially and on the timeline for the project. This makes attrition a very painful reality for all parties involved. This is where understanding that HEDIS Project Management and the proper execution of recruitment is the key to the ultimate success which is a passed NCQA audit for that season. 

Researchers (vendor centric) – This position is exactly as the Abstractor position described above in every way with a few additions. While an Abstractor may be reviewing medical records in hopes of securing the details of one or more measures, the researcher can review this same set of medical records looking for any missing components of other measures helping to satisfy multiple needs through a correct, multi-faceted, view of the medical record. Again, the requirements for this position as above are among the most extensive for this temporary position. 

Over Readers (vendor centric) – On the equivalent of the Researcher, this role holds a deep understanding of HEDIS measures, and the HEDIS process. It is the Over Reader job be the vendor to client final review and satisfaction of measures and their passed or failed requirements. This individual needs an extensive understanding of not only HEDIS but goals of the payer/client, as well as a good working relationship with their lead and project manager. As with the Abstractor and Researcher this role provides “real problems” in terms of cost and ultimate project success if attrition is a problem. It is more important than ever to properly recruit this position.

Records Retrieval or Pursuit (vendor centric) – Without medical records, you have no HEDIS project. This position is s bit complicated and one of the fastest changing roles in the industry. The job has evolved from remote workers copying records at the practitioner’s office, to call centers, to internet phones and software solutions. Some with disastrous results. In fact, like all HEDIS, this role is best served as a hybrid of people and tech. While this position is the lowest paid position it is an exceedingly difficult role to fill in terms of skills, coupled with HIPAA requirements, coupled with the demands of the project. Our vetting process here should understand that this role often serves as a gateway role into HEDIS, if not into healthcare itself. This vetting should include  background checks,  interview,  and rudimentary HEDIS knowledge test as a baseline. The knowledge test should have a simple purpose of finding individuals who have any understanding of HEDIS and those who do not.

HEDIS Positions Summary and Medlinks Staffing Contact Details:

Technology and the future of HEDIS is a discussion that many people around the world are tackling daily. The current process changes each season with NCQA planning substantial changes along the way. In the meantime, corporate America has discovered HEDIS and so the profit margins are of deep concern for all involved. The next tech boom will cycle up to HEDIS and AI is a particularly viable choice for the rapid changes likely to occur in HEDIS over the next decade. 

While tech will invariably play a huge role in the future, the projects will likely have versions of every role described above. Tech will simply reduce the payroll for people needed by the payer as tech improves productivity managed by these roles.

This means for the remaining staff we need to properly address the complexity of short-term staff engaging in a high skill required short term project. 

Finally, the “care” of these short-term staffers can be overlooked by the client who needs this staff. As the stakes rise in the HEDIS game so does the competition and so firms who understand what is at stake will spend the budget dollars on the staff. This proper budgeting is not only important in terms of reimbursement for staff but is critical in terms of the training, the train the trainer procedures, schedule flexibility, and the many tiny tweaks that smart leaders are willing to offer today’s remote workforce.

Medlinks Staffing, LLC has staffed the countries second largest project for the last eleven seasons. We offer HEDIS testing, measure testing, and a variety of other smart search capabilities to help make your project a success.

info@medlinksinc.com