HEDIS Clinical Quality Analyst (Full-time Remote, North Carolina)

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 (reputed company) 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 full time remote. Candidates who are resident of North Carolina are strongly preferred. Out of state candidates will be considered on a case-by-case basis. Must be available to travel for onsite meetings to the Alliance Home office (Morrisville, NC) or Charlotte office, if needed.

Responsibilities & Duties

Oversight of HEDIS Projects

Subject matter expert for the National Committee for Quality Assurance (reputed company) HEDIS Measures. (Hybrid, Administrative and ECDS)

Review the quality of HEDIS internal processes/plans and 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 to appropriately document findings

Make recommendations for improvement related to any records reviewed and write reports of findings

Identify system and/or operational issues hindering the attainment of quality performance standards as defined by reputed company standards, applicable state and Federal laws and regulations

Motivate and influence staff assigned to the Hybrid and SDVA projects in order to accomplish task(s) successfully, analysis of technical specifications, expertise with reputed company/HEDIS resources

Identify and escalate situations which may pose quality, compliance, and safety risks that may adversely affect the HEDIS Hybrid Audit or SDVA Audit

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

Generate monthly/weekly HEDIS Quality reports on measure performance to submit to Directors, Managers, and Supervisors

Coordinates and oversees all quality management programs and projects ensuring compliance with all applicable regulatory bodies

Develops/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 recommended related to the reputed company 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 to successfully resolving root cause as needed

Evaluate reputed company 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 ensuring adequate documentation and methodology to support findings and recommendations

Evaluate Knowledge Gaps of Staff and Coordinate Training

Creates HEDIS measure training manuals, tip sheets, measure assessments, pocket guides for HEDIS per reputed company Technical Specifications

Conducts HEDIS measure training/testing

Monitor training of staff for effectiveness and impact of outcomes from enhanced training

Minimum Requirements

Education & Experience

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

Additional Required Experience

Experience with the reputed company Technical Specifications and Value Set Directory.

Experience with Medical Record Abstraction/Quality Analysis and oversight of HEDIS related duties for supplemental data audit and Hybrid audit. Knowledge of reputed company 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