Senior Quality Analyst - Peak Health

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in Healthcare Administration, Business Administration, Finance, Economics, Information Systems, or a closely related field

EXPERIENCE:

1. Five (5) years of experience in Quality, Stars, Regulatory Reporting or related field within the healthcare industry.

2. Three (3) years of experience working with claims data to evaluate reimbursement changes, payment discrepancies, medical expense opportunities and quality outcomes.

3. Strong knowledge of Quality methodologies and reporting/regulatory requirements (e.g., CMS-HCC).

4. Strong knowledge of CMS Stars Ratings measures including HEDIS, CAHPS, PQA/Pharmacy, HOS, and CMS Display measures.

5. Proficiency in data integration tools and techniques. Strong knowledge of database management systems (e.g., SQL, NoSQL), data modeling, ETL processes, and data warehousing concepts. Experience with data visualization and analytics tools (e.g., SAS Enterprise Guide, SAS Visual Analytics, Tableau, Power BI) is preferred.

6. Demonstrated ability to analyze complex data sets, identify patterns, and derive actionable insights. Familiarity with statistical analysis and machine learning techniques is a plus.

7. Exceptional problem-solving and critical-thinking abilities, with a keen attention to detail. Ability to identify and resolve technical issues in a timely manner.

8. Flexibility to adapt to changing priorities and business needs. Ability to thrive in a fast-paced and dynamic environment.

9. Strong interpersonal and communication skills, both written and verbal, to effectively collaborate with cross-functional stakeholders.

PREFERRED QUALIFICATIONS:

EXPERIENCE:

1. Master's Degree in Healthcare Administration, Business Administration, Finance, Economics, Information Systems, or a closely related field

2. Three (3) years of experience working with Medicare and/or Medicaid Data

3. Knowledge of Medicare HEDIS and STARS forecasting

4. Knowledge of ICD Diagnosis, CPT, UB, HCFA coding and understanding

5. Understanding of CMS Medicare Regulatory Reporting

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Stars Operations:

• Familiarity with HEDIS, CAHPS, PQA/Pharmacy, HOS, and CMS Display measures and/or other health care quality metrics.
• Develop standard reports, tracking tools, metrics to monitor vendor performance, Stars/Quality measures, tactics, and initiatives.
• Support the Stars Program strategy, objectives, and initiatives through the creation of reports and/or analysis to drive a year over year 4 overall Stars rating.
• Work with Stars Program leader(s) to develop and execute Stars-focused roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective.

2. Collaboration:

• Provide subject matter expertise, support, and training, as needed, for both the Quality and Stars programs.
• Ability to work collaboratively across many teams, prioritize demands from those teams, synthesize information received, and generate meaningful conclusions.
• Foster a positive and collaborative work environment, encouraging teamwork and professional growth.
• Develop and implement training programs to enhance the skills and knowledge of the team.
• Support the development, integration, and maintenance of Stars initiatives. Ensure maximization of initiative for Stars, Quality, and Regulatory requirements.

3. Compliance and Reporting:

• Ensure compliance with all applicable regulatory requirements, guidelines, and contractual obligations related to Quality, HEDIS, and Stars.
• Reconciliation of reporting to ensure accuracy and timely completion.
• Prepare and submit reports on Quality, HEDIS, and Stars performance, highlighting key metrics, trends, and areas for improvement.
• Must possess current understanding of how compliance and quality programs such as Medicare STARS, HEDIS, and NCQA affect the Plan.

4. Performs other duties as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Working on a computer.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Remote

SKILLS AND ABILITIES:

1. Strategic thinking.

2. Excellent written an oral communication.

3. Analytical.

4. Strong problem solving and quantitative abilities.

5. Attention to detail.

6. Experience with Medicare and Medicaid products.

7. Working knowledge of claims, utilization management, member, and/or provider data.

8. Strategic thinking.

9. Effective time management and organizational skills.

10. Work independently as well as in a team environment.

11. Proficient with Microsoft Office.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center: