Director Hedis Reviewer Jobs (NOW HIRING)

Job Category: Clinical Management

Requisition Number: DIREC001281

• Full-Time
• Hybrid

Showing 1 location

Brooklyn OH
100 American Rd
Cleveland, OH 44144, USA

Directs operations and staff engaged in Healthcare Effectiveness Data and Information Set (HEDIS) and clinical quality improvement analytics and supplemental data functions. Ensures adherence to reporting requirements of the National Committee on Quality Assurance (NCQA), and regulatory agencies. Leverages and delivers clinical quality improvement management data and reporting that support the health plan’s strategies, goals, and initiatives for all lines of business (Commercial, Marketplace, Medicare Advantage, and Stars).

• Directs the HEDIS annual submission process. Develops and manages work plans; establishes and ensures timelines are adhered to, assigns responsibilities, and monitors and reports progress to internal stakeholders.
• Directs and coordinates the preparation of the HEDIS roadmap including all data sources and exchanges with vendors and providers.
• Leads strategic planning based on reporting and year over year comparisons for continual process improvement of Stars and HEDIS scores and overall accreditation for all lines of business.
• Measures trends, discusses reasoning behind trend, and calls out any significant changes.
• Leads the process for defining operational improvements within the health plan based on HEDIS performance following the annual HEDIS audit.
• Builds relationships with internal and external customers. Communicates progress and results through presentations to key stakeholders, including senior leadership.
• Presents at Joint Operating Committee (JOC) meetings with Physicians and Administrative Health System leadership.
• Leads strategic projects related to the use of supplemental data (internal, external and in the vendor space) to enhance performance for all lines of business for HEDIS improvement results and overall HealthPlan scores.
• Enhances reporting for Member Assistance Program (MAP) members and other clinical areas to identify assigned staff to cases for tracking and care gap closure opportunities.
• Collaborates with internal stakeholders to ensure data warehouse architecture development and utilization.
• Directs the supplemental data team responsible for Extraction, Transformation and Loading (ETL) including the design, building, testing, and maintaining of ETL jobs.
• Oversees the translation of functional ETL requirements into technical design elements to be utilized by internal teams for managing and maintaining supplemental data.
• Directs external client relationships with regards to supplemental data including providing technical specifications to clients (SFTP set-up, file layout, etc.), establishing a cadence for data submission, monitoring the processing of data files, and working with the client to improve the impact of supplemental data on HEDIS measures.
• Develops and maintains Value-Based Consulting (VBC) reporting to support the VBC contracting outcomes and team.
• Participates in contracting calls with Provider groups to supply details on supplemental data files and care gap measures scores. Collaborates with provider groups key contacts to enhance the data files.
• Manages staff developing quality measurement analytics and reporting for internal use and regulatory submissions including staffing, training and development and performance management. Ensures deliverables are reliable, valid, and actionable.
• Performs other duties as assigned.

• Bachelor’s Degree in Business or Health Care Administration, Public Health, or a related field.
• 8 years of experience in health plan or health care analytics which includes HEDIS and clinical quality improvement, 5 years of which is in a leadership capacity.

• Comprehensive knowledge of the end-to-end HEDIS cycle (e.g., abstraction, data submission, audit, etc.) and the ability to apply advanced concepts to Company operations.
• Expert knowledge of and proficiency with NCQA-certified HEDIS software.
• Extensive knowledge of NCQA and CMS measurement, reporting and regulatory requirements.
• Intermediate to advanced knowledge of and proficiency with analytic programming languages and data visualization tools, including SAS, SQL, Cognos, Tableau, and Microsoft Visual Studio.
• Familiarity with multiple data source formats, including delimited flat files, web services, and SharePoint list XML.

We maintain a drug‑free workplace and perform pre‑employment substance abuse and nicotine testing.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.