HEDIS RN

Actively looking to hire multiple RNs that are looking for a HEDIS role. This role is starting in November - must have at least 3 seasons of HEDIS completed as well as an active RN license. LPNs are not being considered at this time. Responsibilities

- Review clinical data and documentation to determine claim payment decisions based on internal policies and National Committee for Quality Assurance (NCQA) guidelines.
- Evaluate denied claims to determine whether to overturn or uphold the denial, and submit complex or unclear cases to the Medical Director for further review.
- Prepare comprehensive case reviews for the Medical Director when medical necessity criteria are not met based on the available clinical information.
- Generate clear and accurate appeal resolution communications to members and providers in accordance with company policies and NCQA guidelines.
- Create system authorization events for decisions where previously denied claims are overturned.
- Request additional clinical information from providers, as appropriate, to facilitate timely and thorough appeals resolution.
- Gather, organize, and prepare case information and documentation for Administrative Law Hearings.
- Maintain the appeals process within prescribed NCQA timeframes, ensuring compliance with turnaround requirements and accurate tracking in the appeals database.
- Assist the Medical Director in revising, updating, and creating new policies and procedures to satisfy NCQA standards and contractual requirements.
- Apply nursing knowledge, including familiarity with HEDIS measures and medical guidelines, to support accurate and consistent utilization and appeals review.

Essential Skills

- Active RN license.
- Nursing background with exposure to HEDIS and medical quality measures.
- 3+ seasons of recent HEDIS experience
- Comfortable working with electronic systems and databases to track appeals and authorization events.

Work Environment This position operates in a professional clinical and administrative setting focused on medical necessity and appeals review. Work is primarily computer-based, using Microsoft Office and internal systems to review clinical documentation, track appeals, and generate communications. The role requires adherence to NCQA timeframes, regulatory standards, and contractual requirements, with a strong emphasis on accuracy, timeliness, and collaboration with Medical Directors and other clinical staff. Standard business attire is expected in office or hearing settings, and the environment supports detailed, focused work on complex medical and regulatory cases.
Job Type & Location
This is a Contract position based out of Tampa, FL.
Pay and Benefits
The pay range for this position is $38.00 - $42.00/hr. Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors. Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:

Medical, dental & vision
Critical Illness, Accident, and Hospital
401(k) Retirement Plan Pre-tax and Roth post-tax contributions available
Life Insurance (Voluntary Life & AD&D for the employee and dependents)
Short and long-term disability
Health Spending Account (HSA)
Transportation benefits
Employee Assistance Program
Time Off/Leave (PTO, Vacation or Sick Leave)
Job Type & Location
This is a Contract position based out of Tampa, FL.
Application Deadline
This position is anticipated to close on Nov 11, 2026.
Workplace Type
This is a fully remote position. About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service.

The company is an equal opportunity employer and will consider all applications without
regard to race, sex, age, color, religion, national origin, veteran status, disability,
sexual orientation, gender identity, genetic information or any characteristic protected
by law.

If you would like to request a reasonable accommodation, such as the modification or
adjustment of the job application process or interviewing process due to a disability,
please email [email protected] for other accommodation options.

San Francisco Fair Chance Ordinance:
Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the
city and county of San Francisco, we will consider for employment qualified applicants
with arrest and conviction records.

Massachusetts Lie Detector:
It is unlawful in Massachusetts to require or administer a lie detector test as a
condition of employment or continued employment. An employer who violates this law
shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI):
We may use Artificial Intelligence (AI) to support parts of our hiring process,
including sourcing, screening, and evaluating candidates. AI helps assess applications
and qualifications, but final decisions are made by our hiring team. By applying, you
acknowledge and agree that your application may be reviewed using AI tools.