National Quality HEDIS Data Program Specialist

People. Passion. Purpose.

At P3 Health Partners, our promise is to guide our communities to better health, unburden clinicians, align incentives and engage patients.

We are a physician-led organization relentless in our mission to overcome all obstacles by positively disrupting the business of health care, transforming it from sickness care into wellness guidance.

We are looking for a HEDIS Program Specialist. If you are passionate about your work; eager to have fun; and motivated to be part of a fast-growing organization across multiple markets, then you should consider joining our team.

Overall Purpose:

HEDIS Data Program Specialist assists in managing the HEDIS reporting process for healthcare organizations. By ensuring clinical quality and outcomes meet quality standards, they play a vital role in the organization’s success.

Perform duties to ensure HEDIS data accuracy and reporting, including investigation, auditing, and improvement opportunities. Assist with quality improvement initiatives in the markets and across the enterprise. Responsible for tracking company’s data used to measure performance on important dimensions of care and service.

Responsible for serving as the liaison between the markets/business team and the technical team in translating complex business information needs to quality engineers and health plan partners.

The HEDIS Data Program Specialist participates in all aspects of the Healthcare Effectiveness Data and Information Set (HEDIS) data collection, analysis, and reporting process, ensuring the health plan meets quality standards set by the National Committee for Quality Assurance (NCQA) by optimizing patient care and identifying areas for improvement based on HEDIS measures under the guidance of the Quality Manager and Chief Administrative Officer. Through internal, health plan, provider, and patient identification, the HEDIS Program Specialist works to improve the organization quality scores, ensuring members have the health care experience they deserve. This position creates and promotes data accuracy as well as implementing and executing quality improvement projects.

Education and Experience:

• Bachelor’s degree in a related field, master’s preferred
• Minimum of 5 years experience with data analysis
• Minimum of 3 years in a healthcare environment
• Experience with HEDIS Technical Specifications, guidelines, reporting and HEDIS survey process
• Experience in Project Management
• Experience utilizing various software packages including SharePoint, Excel, Access, PowerPoint and Word
• Extensive Excel skill required; SQL skills preferred
  
  
  

Knowledge, Skills and Abilities:

• Knowledge of HEDIS Quality Management Measure Specifications
• Knowledge of federal, national, state, and health plan regulatory requirements, as well as managed care and health plan standards
• Knowledge of the CMS Star Rating or MIPS, MACRA, or a federal incentive-based program
• Strong analytical and critical thinking skills
• Ability to learn and adapt to multiple technology platforms
• Excellent communication and collaboration skills to work with health plans and internal teams
• Project management skills to manage data discrepancies and complex quality improvement initiatives
• Able to think and work effectively under pressure
• Ability to function effectively within multidisciplinary teams
• Ability to effectively prioritize multiple tasks and deadlines and accurately complete tasks within established times
• Knowledge of medical terminology and coding (ICD-10, CPT, CPTII, LOINC, SNOMED)
• Goal-oriented, self-motivated, organized, team player, problem solver, etc.
• Aware of HIPAA rules regarding patient health information security
• Ability to meet and manage deadlines
  
  
  

Essential Functions:

• Reporting and Analysis: Generating reports on HEDIS performance, identifying trends, and presenting findings to department and executive leadership for decision-making. Ensure data accuracy and calculated scoring. Reports include Monthly Stars Dashboard, QM productivity reports, HealthPlan Reconciliation, and NQUC presentations. Coordinate with clinical staff to inform them of missing screenings and HEDIS gaps. Download patient records and upload them to insurance portals to close quality gaps.
• Data Management: Collecting, reviewing, and analyzing standard and non-standard data extracts for HEDIS gap closures. Ensuring Affiliate Provider EMR Files are received and loaded along with ensuring expected gap closures are reflected in QM system. Review ACO internal QM data and reconcile with CMS files.
• Quality Improvement Initiatives: Identify new digital HEDIS data capture opportunities and gap closure strategies. Assist with provider EMR data collection and/or data extract set-up.
• Provider Engagement: Collaborating with market Provider Engagement Teams to ensure accurate gaps in care are presented on provider reports.
• Audit Preparation and Reconciliation: Reconciliation with Health Plans, GIC files, and Health Plan EMR files. Coordinating with external auditors to ensure readiness for HEDIS audits and address any identified issues. QM Liaison with Analytics to identify and correct data errors found.
• Vendor Management: Managing various vendors across markets ensuring data sharing gaps, monitoring productivity and closure metrics. Responsible for sending and receiving weekly/monthly vendor quality worklists and sharing results with markets.
• Compliance: Staying updated on NCQA HEDIS guidelines and adherence to health plan regulatory requirements.