Job Summary

The Senior Manager who will also function as a HEDIS Project Lead is the accountable business and clinical owner of the HEDIS and Core Measure program across all product lines. This role is responsible for clinical interpretation of measures reporting strategy audit readiness and cross-functional coordination to ensure HEDIS and Core Measure results are accurate compliant and defensible.

This role serves as the primary authority for what is reported and why partnering closely with the HEDIS/Core Measure Technical Lead MRR leadership and business stakeholders. The role operates on a year-round cadence supporting design validation production audit and submission activities.


Essential Functions:

• HEDIS Program & Clinical Leadership
  Owns overall HEDIS and CMS Core Measures clinical strategy and reporting intent across product lines
  Interprets NCQA HEDIS specifications CMS Core Measures specifications FAQs and technical guidance
  Determines measure inclusion/exclusion hybrid vs. administrative approach and reporting decisions
  Provides clinical judgment and escalation support for complex or ambiguous scenarios
  Monitors NCQA HEDIS updates CMS Core Measures updates technical bulletins FAQs and measure changes
  Assess the impact of upcoming HEDIS and CMS Core Measure changes on organization programs data sources and workflows
  Partners with IS (Information Systems) to identify and ensure changes are made outside of production season:
  New or modified measures
  Required data sources or automations
  Requirements or simplifications of existing logic
  (25%)

• Medical Record Review (MRR) Oversight
  Partners with the MRR Manager on MRR strategy reconciliation and quality oversight
  (10%)

• QA / UAT (Clinical)
  Owns clinical QA/UAT for:
  New or modified measures
  HEDIS and Core Measures main software (Cotiviti) data and refreshes plus other Supplemental Data Sources (SDS)
  CAHPS samples and outputs
  Confirms outputs align with clinical intent prior to audit and submission
  (25%)

• Audit & Roadmap Ownership
  Owns business and clinical content of the HEDIS and CMS Core Measures Roadmap
  Leads clinical responses to audit questions and issue logs
  Serves as a primary clinical point of contact for external auditors
  (25%)

• Cross-Functional Leadership
  Works closely with IS Product Line Managers (PLMs) Population Health/QI MRR and vendors
  Ensure business stakeholders are engaged early and consistently
  Supports governance and decision-making across the HEDIS and CMS Core Measure lifecycle
  (15%)

Education:

• Bachelors degree in healthcare public health nursing health administration or related field required

Work Experience:

• 4-6 years of experience in HEDIS quality measurement NCQA or healthcare quality analytics required AND

• 1-3 years clinical background (RN) or equivalent clinical informatics experience required AND

• 3-5 years previous management experience required

Licenses:

Knowledge Skills and Abilities:

• Demonstrated experience interpreting HEDIS measures and NCQA requirements

• Experience supporting or participating in HEDIS audits

• Strong written and verbal communication skills including audit-facing communication

• Preferred Qualifications
  
  7 years of progressive HEDIS or quality program leadership experience
  
  Demonstrated experience interpreting CMS Core Measures and CMS reporting requirements
  
  Experience serving as a primary clinical lead or decision-maker during an audit
  
  Familiarity with HEDIS vendor platforms (e.g. Cotiviti)
  
  Experience supporting CAHPS processes and submissions