The HEDIS Clinical Quality Analyst provides clinical direction, guidance, training, and quality oversight for all things related to the clinical aspect of Healthcare Effectiveness Data and Information Set (HEDIS). This position would oversee abstraction, overreads and quality analysis of HEDIS for both Prospective and Retrospective Seasons to ensure the company complies with the standards set by the National Committee for Quality Assurance (NCQA) and Centers for Medicare & Medicaid Services (CMS). Performs quality improvement activities to monitor/maintain quality of care and compliance with applicable standards/regulations. Performs/coordinates HEDIS data collection, medical record review, and quality improvement activities as indicated.

This position will allow the successful candidate to work a schedule that will be primarily remote. While there is no expectation of being in the office routinely, they will be required to come into the Alliance Office for business and team meetings as needed.

Responsibilities & Duties

Oversight of HEDIS Projects

• Subject matter expert (SME) for the National Committee for Quality Assurance (NCQA) HEDIS Measures. (Hybrid, Administrative and ECDS)
• Review the quality of HEDIS internal processes/plans for alignment with procedures and/or best practices for supporting the HEDIS Team.
• Responsible for participating in the development, research, and implementation of HEDIS improvement activities
• Plan implementation of Primary Source Verification (PSV) and Medical Record Review Validation (MRRV) Audits
• Oversees quality of abstraction, quality assurance (QA) and second level QA for HEDIS Hybrid Project and Supplemental Data Audit
• Interpret qualitative and quantitative information and appropriately document findings
• Make recommendations for improvement related to records reviewed and report findings
• Identify system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA, applicable state and Federal laws and regulations
• Motivate, influence, and provide direction to staff assigned to the Hybrid and SDVA projects to ensure successful completion of project goals, deliverables, and timelines
• Analyze and interpret technical specifications, business requirements, and regulatory guidance to support accurate implementation of HEDIS measures and project activities
• Serve as a subject matter expert on NCQA and HEDIS resources, providing guidance, training, and consultation to project teams
• Identify and escalate situations which may pose quality, compliance, and/or safety risks that may adversely affect the HEDIS Hybrid Audit, HEDIS Prospective Audit or SDVA Audit

Coordinate/Oversees Data Analysis and Quality Intervention and Report on Findings

• Generate monthly/weekly HEDIS Quality reports on measure performance and submit to Directors, Managers, and Supervisors
• Coordinates and oversees all quality management programs/projects ensuring compliance with all applicable regulatory bodies
• Develops and implements quality management and error reduction programs as needed
• Provide written feedback to Directors, Managers and Supervisors concerning quality concerns pertaining to individual performance, compliance risks/trends, root cause analysis and any system or process improvements recommendations related to the NCQA HEDIS measures

Effectively Measure the Key Output Variables to Ensure All Performance Changes are Accurately Assessed

• Prepare analysis of initial and repeat HEDIS measures to evaluate efficacy of interventions and to improve approach for successfully resolving the root cause as needed
• Evaluate validity and accuracy of supplemental data sources to draw appropriate conclusions

Analyze Changes in Performance to Determine the Impacts of Interventions

• Perform any required data analysis to evaluate gaps in care
• Prepare comprehensive reports to ensure adequate documentation and methodology to support findings and recommendations

Evaluate Knowledge Gaps of Staff and Coordinate Training

• Creates/Updates HEDIS measure training manuals, tip sheets, measure assessments, pocket guides for HEDIS per NCQA Technical Specifications, annually
• Conduct HEDIS measure training/testing yearly
• Monitor training of staff for effectiveness and impact of outcomes from enhanced training

Minimum Requirements

Education & Experience

Required:

Graduation from an accredited school of nursing with a Registered Nurse (RN) license or Licensed Practical Nurse (LPN) and five (5) years of healthcare experience in HEDIS clinical quality and process improvement.

Additional Required Experience:

Experience with the NCQA Technical Specifications and Value Set Directory.

Experience with Medical Record Abstraction/Quality Analysis and oversight of HEDIS related duties for HEDIS to include the supplemental data audit, Prospective audit and Hybrid audit. Knowledge of NCQA Health Plan HEDIS data collection and reporting requirements and processes.

Understanding of the operational requirements for data collection in support of HEDIS or similar Quality programs.

Experience with the Medicaid population related to HEDIS Measures.

Preferred:

Data analysis and IT infrastructure of standard and non-standard data related to supplemental data experience.

Certified Professional in Healthcare Quality - CPHQ preferred.

Knowledge, Skills, & Abilities

• Knowledge of North Carolina State and Federal rules and requirements related to the service continuum in North Carolina
• Knowledge of Tailored Plan, Integrated Care and Care Management processes and regulatory requirements
• Knowledge of best and promising practices for behavioral & physical health and/or intellectual/developmental disabilities
• Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or other online survey tool)
• Strong clinical skills
• Problem solving skills
• Interpersonal Skills
• Strong Analytical skills
• Problem solving and conflict resolution skills
• Strong diplomacy skills and discretion
• Highly effective communication skills
• Ability to negotiate and resolve issues with minimal assistance

Salary Range

$79,425 - $101,267/Annual

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity

An excellent fringe benefit package accompanies the salary, which includes:

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility