Medicare HEDIS® and Star Ratings: A Comprehensive Review for Case Managers

Activity description

Each year, the Centers for Medicare & Medicaid Services (CMS) publishes Star Ratings for each Medicare Advantage health plan. CMS Medicare Advantage Star Ratings measure how well providers and Medicare Advantage plans are delivering care to consumers and the quality of health and drug services received by Medicare consumers enrolled in these plans. CMS Star Ratings allow Medicare consumers to compare the quality of available Medicare health and drug plans to ensure they can make the best health care decisions for themselves when selecting a Medicare Advantage plan. The National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS) tool is a set of measures used by health care organizations to evaluate the quality of care provided to patients. Medicare HEDIS performance measures are included in the Star Ratings system for Medicare Advantage health plans.

This six-part series will provide a comprehensive overview of the critical role case managers play in improving CMS Star Ratings and Medicare HEDIS measures when coordinating care for Medicare members.

Course last reviewed: 12/11/2023

Provided by
This activity is provided by Optum Health Education and Optum.

Commercial support
No commercial support was received for this activity.

Hardware/Software Requirements
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Target Audience

This activity is designed to meet the educational needs of case managers, nurses and social workers.

Learning Objectives

At the end of this educational activity, participants should be able to:

  • Define HEDIS measures and Star Ratings.
  • Identify the specific HEDIS measures associated with standard case management, post-care, preventative care, medical conditions and behavioral health diagnoses.
  • Recall the education and interventions discussed with each HEDIS measure that case managers can provide to patients to help close gaps in care.
Activity summary
Available credit: 
  • 3.00 ANCC - Nurses
  • 3.00 Attendance - General Attendance
  • 3.00 CCMC - General - Case Managers
  • 3.00 ASWB - Social Workers
Activity opens: 
Activity expires: 

Rebecca Gleason, RN, CCM
Clinical Planner
Optum Health Education

Lori Harris, RN, MHA, CPHQ, CMAC
Vice President
Clinical Adherence and Remediation/
Practice Health and Safety, Clinical Consistency
Clinical Performance, Optum Health

Nancy Maylum, RN 
Clinical Quality Training Consultant
Education, Training, and Regulatory Updates
Clinical Performance, Optum Health

Lynda Sweet, LPN 
Clinical Quality Training Consultant
Education, Training, and Regulatory Updates
Clinical Performance, Optum Health

Disclosures of relevant financial relationships
In accordance with the Accreditation Council for Continuing Medical Education's (ACCME) Standards for Integrity and Independence in Accredited Continuing Education, Optum Health Education (OHE) requires all those in control of educational content to disclose their financial relationships with ineligible companies within the prior 24 months. Ineligible companies are defined by the ACCME as companies whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. Individuals must disclose all financial relationships, regardless of the amount, with ineligible companies and regardless of their view of the relevance of the relationship to the education. OHE ensures that the content is independent of commercial bias.

The activity faculty/planners have no financial relationships to disclose.

Method for calculating CE credit
CE credit was calculated by the complexity of content.

Accreditation Statement
Joint LogoIn support of improving patient care, this activity has been planned and implemented by Optum Health Education and Optum. Optum Health Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

Credit Designation Statements

The participant will be awarded up to 3.00 contact hour(s) of credit for attendance and completion of supplemental materials.

Nurse practitioners
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.

Case managers
The Commission for Case Manager Certification has approved this program for a maximum of 3.00 clock hours for Certified Case Managers (CCM).

Social workers
ACE LogoAs a Jointly Accredited Organization, Optum Health Education is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Optum Health Education maintains responsibility for this course. Social workers completing this course receive 3.00 enduring continuing education credits.

A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization with which they wish to obtain credit.

Available Credit

  • 3.00 ANCC - Nurses
  • 3.00 Attendance - General Attendance
  • 3.00 CCMC - General - Case Managers
  • 3.00 ASWB - Social Workers
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