Job Description

The HEDIS Audit Quality Manager is responsible for managing all HEDIS Audit activities for all lines of business, region of the company, market, and/or enterprise wide which are necessary for submission of audited HEDIS and CAHPS results to NCQA, CMS, and State Regulatory Agencies. Primary duties may include, but are not limited to:

• Interfaces with internal and external clients, quality committees, and departments in the review of HEDIS submissions and requirements.
• Manages the overall HEDIS audit processes and resources required to successfully lead the team.
• Evaluates, interprets and summarizes HEDIS audit guidelines and manages the process for HEDIS submission activities.
• Identifies appropriate resources and accountabilities for project teams involved with the HEDIS audit.
• Conducts the ongoing evaluation and interpretation of NCQA, CMA, and State HEDIS requirements to ensure compliance through reporting and measurement studies/ methodologies.
• Serves as expert resource to quality committees and business owners across the organization.
• Leads and provides oversight of quality studies/projects.
• Facilitates project management and develops comprehensive HEDIS audit work plans by establishing deliverables, accountabilities, and timelines.
• Performs quantitative and qualitative analysis of quality related data and reports activities, improvements, and recommendations to the quality committee.
• Coordinates with health plans on state specific audits and reporting requirements.

Minimum Requirements:

• Requires a BA/BS in a health care field and minimum of 3 years healthcare-related experience, in addition, minimum of 3 years’ experience in a QA/QI related position; or any combination of education and experience, which would provide an equivalent background.

Preferred Qualifications:

• Extensive experience managing the overall HEDIS audit processes for all lines of business with both National and Medicaid State Auditors.
• Strong knowledge of the NCQA HEDIS audit guidelines and processes used to submit HEDIS to the National and State HEDIS auditors.
• Experience creating and managing a large project plan that identifies appropriate resources and accountabilities for project teams involved with the HEDIS audit.
• Experience leading mock interviews with internal departments to prepare for the external HEDIS Audits.
• HEDIS audit experience preferred.
• Experience with Medicaid preferred.

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