Anita Jones
HEDIS Review Nurse | Clinical Quality Abstraction Specialist
Tampa,FL
Summary
Highly skilled Licensed Practical Nurse and HEDIS Review Specialist with over 10 years of experience in clinical quality abstraction, medical record review, and utilization management. Expert in CMS, NCQA, and HEDIS guidelines with proven success supporting risk adjustment and quality reporting programs. Adept at leveraging data accuracy, analytical thinking, and attention to detail to optimize compliance and healthcare outcomes.
Overview
14
14
years of professional experience
2
2
Certifications
Work History
Utilization Review Nurse
Elevance/Anthem
01.2018 - 01.2025
- Performed comprehensive HEDIS chart abstraction and quality audits supporting CMS and NCQA compliance measures.
- Annotated medical records in Adobe PDF and entered data in EMMA and Excel for quality tracking.
- Collaborated with providers to verify medical documentation, ensuring completeness and regulatory adherence.
- Identified documentation trends, reported findings, and contributed to process improvement initiatives.
- Remote
Inpatient Care Nurse
WellCare Management – FL Market
10.2015 - 10.2017
- Supported quality improvement through patient record review and post-discharge coordination.
- Applied CMS and UR standards to determine medical necessity and optimize resource utilization.
- Documented outcomes and referrals aligned with disease and case management metrics.
Quality Improv. Nurse – Risk Adj.
Aetna
03.2013 - 10.2015
- Conducted medical record audits for inpatient and outpatient services aligned with quality improvement standards.
- Ensured data accuracy and regulatory compliance with NCQA and HEDIS specifications.
- Served as a subject matter expert for non-clinical staff in clinical documentation and abstraction accuracy.
Utilization Review Nurse
WellCare-Centene (Contract)
10.2012 - 02.2013
- Audited case management and disease management files for completeness and regulatory compliance.
- Ensured consistency with HEDIS technical guidelines and CMS quality specifications.
HEDIS Review Nurse
Med Assurant
01.2011 - 05.2012
- Abstracted medical records for HEDIS measures and quality projects.
- Verified compliance with NCQA and state quality reporting standards.
- Ensured data accuracy for reporting and performance improvement.
Education
Practical Nurse Program, LPN - undefined
Fortis College
Tampa, FLCertified Nursing Assistant, Emergency Medical Technician - undefined
Learey Technical College
Tampa, FLSkills
7 years of experience conducting medical record abstraction and HEDIS data validation for leading health organizations
Achieved 98–100% data accuracy rates in clinical documentation and abstraction performance
Proficient in Adobe PDF, EMMA, InterQual, Milliman, and MS Office tools for abstraction workflow and reporting
Deep understanding of CMS and NCQA requirements, HIPAA compliance, and PHI protection
HEDIS Abstraction
Quality Reporting
NCQA & CMS Compliance
Medical Record Analysis
Data Integrity
Utilization Review
Clinical Documentation
ICD-10 & CPT Coding
Audit & Validation
EMMA
Milliman
InterQual
Adobe Acrobat
Microsoft Excel & Word
Certification
WellCare University – NCQA HEDIS Project MRR Season & Updates (2017)
Timeline
Utilization Review Nurse
Elevance/Anthem
01.2018 - 01.2025
Inpatient Care Nurse
WellCare Management – FL Market
10.2015 - 10.2017
Quality Improv. Nurse – Risk Adj.
Aetna
03.2013 - 10.2015
Utilization Review Nurse
WellCare-Centene (Contract)
10.2012 - 02.2013
HEDIS Review Nurse
Med Assurant
01.2011 - 05.2012
Practical Nurse Program, LPN - undefined
Fortis College
Certified Nursing Assistant, Emergency Medical Technician - undefined
Learey Technical College