Job Summary

Under minimal supervision, the HEDIS manager will oversee the Health Employer Data Information Set (HEDIS), and HOS survey project timelines; collaborates with vendors and internal IT department to ensure all data requirements and submissions are accurate and timely. Supports Population Health and QI teams with metric data and strategy for MCR Stars, Medicaid MLR and NCQA certification. Promotes positive interpersonal (customer) relationships with fellow employees, physicians, patients and visitors. Supervises RN, Medical Records HEDIS personnel.

Essential Functions:
• Data Project Management: Oversees the HEDIS/ HOS data collection, development and analysis; maintains and updates appropriate data collection systems and enters information, as required, using MS Office, and Managed Care systems used to extract data for HEDIS/ HOS while driving and providing oversight of post-audit reviews to define operational improvements for future HEDIS cycles. Ensures compliance with all NCQA HEDIS Audit requirements. (15%)

• • Support strategic goals of MCR Stars by providing subject matter expertise on quality metrics and HEDIS strategy (15%)

• • Support NCQA accreditation process by providing subject matter expertise on quality standards (10%)

• Work with providers on appropriate coding and documentation for HEDIS Stars and MLR measures. Oversee post-audit reviews to define operational improvements for future HEDIS cycles. (10%)

• • Process and Procedure: Determines work procedures and expedites workflow; assigns duties and reviews work; prepares necessary and required reports to management. Delegates responsibility/authority. Identifies problems and opportunities for improvement; identifies appropriate solution and involves others in the implementation process. Makes recommendations for cost efficiency and process improvement. Meets all NCQA HEDIS Medical Record Review (MRR) requirements and deadlines. (10%)

• • Reporting and Analysis Prepares and/or reviews daily, weekly, monthly and quarterly quality assessment reports and conducts/reports findings for QI data for all lines of business as required for HEDIS/ HOS activities, lead discussions about data/results, provides timely updates. Meets NCQA Compliance Audit activities to include annual training/testing of HEDIS staff and timely completion of Supplemental Data Audit (SD), Medical Record Review Validation (MRRV, Inter-Rater Reliability (IRR) tracking, and supports HEDIS annual roadmap submission. (10%)

• • Vendor Management: Partners with vendors and manages tracking progress during and prior to submission such as HEDIS auditor and Hedis Data vendor for medical record capture (10%)

• • Staff Management: Creates annual HEDIS training and testing materials per NCQA Technical Specification and compliance audit requirements. Identifies training and staff development needs of employees, recognizes positive behavior and contributions to the staff, using praise, appreciation and rewards, participates in the selection of QI staff, sets performance expectations by developing job specific customer service expectations and behaviors. Promotes guidance/oversight of certain tasks and delegates appropriately. (10%)

• • Oversee post-audit reviews to define operational improvements for future HEDIS cycles. (10%)

Education:

• Bachelor's degree In nursing, health informatics, healthcare administration, public health or related field required

Work Experience:

• 4-6 years Project Management experience, preferably in HEDIS/HOS within a managed care environment required and

• 4-6 years previous experience in performing medical record review, inter rater reliability and working knowledge of medical terminology and NCQA HEDIS Technical Specifications required and

• 4-6 years previous experience with HEDIS quality measurements for health plan STAR ratings and

• 4-6 years previous experience in healthcare, quality improvement, statistics and/or evaluation.

Licenses:

Knowledge, Skills and Abilities:

• Prerequisite skills including collecting, compiling and interpreting HEDIS CAHPS , and HOS data for QI studies

• Extensive knowledge of MCR Stars program and NCQA accreditation process including previous experience with HEDIS quality measurements, health plan STAR ratings and quality reporting

• Knowledge/familiarity with medical terminology, medical record review, NCQA HEDIS Technical specifications, and decision making skills regarding appropriateness of care review.

• Provide HEDIS /HOS data for research design planning and analysis to generate quality improvement reports.

• Applies efficient research and data collection skills and organize information by line of business succinctly

• Ability to work independently as well as collaboratively with other internal and external team members to ensure timelines are met

• Utilizes software applications and information systems to perform work processes with responsibility for training on such and providing updates as necessary

• Demonstrated leadership skills in working with clinical professionals and office staff

• Ability to coach and lead others on a collaborative basis to ensure team success

• Ability to engage physicians, advance care providers, vendors, clinical leaders, and other key stakeholders to deliver member-centered care.

• Demonstrate flexibility in response to unexpected changes.