Medicaid External Quality Review (EQR) Consultant

Job Description

Job Description

Medicaid External Quality Review (EQR) Consultant

Job Type: Long-Term Contract with Extension Options
Work Arrangement: Remote, with travel to client sites as required within the Maryland area

Position Overview

We are seeking an experienced Medicaid External Quality Review (EQR) Consultant to support technical assessments of Medicaid managed care organizations (MCOs). The ideal candidate will have a background in healthcare quality, information systems, auditing, data analytics, or a related discipline, with experience evaluating healthcare data, system controls, and regulatory compliance.

This consultant will lead key technical assessment activities, including CMS EQR Protocol 2: Validation of Performance Measures and Information Systems Capabilities Assessments (ISCAs) . The role involves assessing the reliability, accuracy, completeness, and integrity of information systems and data management practices that support healthcare quality measurement, reporting, and regulatory oversight.

The successful candidate must be comfortable independently managing assessments from initial planning and stakeholder interviews through evidence evaluation, findings development, and final report delivery.

Key Responsibilities

• Lead technical interviews, system walkthroughs, and evidence reviews to assess information systems, operational processes, and internal controls.
• Conduct Information Systems Capabilities Assessments (ISCAs) and technical evaluations of Medicaid managed care organizations.
• Assess healthcare information systems, complex data flows, source data, system interfaces, reporting processes, and controls affecting data quality and reliability.
• Evaluate data integrity, identify potential risks and control gaps, and document objective, defensible findings supported by evidence.
• Apply professional judgment to identify deficiencies, assess their potential impact, and recommend practical improvements.
• Validate CMS Medicaid Adult and Child Core Set performance measures by evaluating MCO-generated rates for potential bias, accuracy, completeness, and reliability.
• Determine the reportability of performance measures based on applicable CMS specifications, validation requirements, and supporting documentation.
• Develop evidence-based findings, recommendations, and technical reports aligned with CMS EQR expectations and applicable regulatory requirements.
• Independently manage assessment activities, including planning, stakeholder coordination, documentation, analysis, and final deliverables.
• Evaluate how information system and process deficiencies may affect performance measurement, performance improvement projects, compliance reviews, network adequacy validation, encounter data validation, and other EQR activities.

Preferred Qualifications

• Experience conducting Information Systems Capabilities Assessments (ISCAs), technical assessments, healthcare audits, or similar evaluations.
• Background in healthcare quality, health information systems, auditing, data analytics, or a related field.
• Demonstrated ability to lead stakeholder interviews and system walkthroughs, evaluate technical evidence, assess controls, and document defensible findings.
• Experience analyzing healthcare data, information systems, data flows, system interfaces, and reporting processes.
• Familiarity with health insurance and managed care operations, including encounter data, claims processing, enrollment data, provider files, and quality reporting systems.
• Experience validating healthcare quality measures, preferably CMS Medicaid Adult and Child Core Set measures.
• Knowledge of relevant measure specifications, reporting requirements, and performance measure validation methodologies.
• Understanding of data governance, data lineage, reconciliation, automated controls, exception management, and reporting validation.
• Familiarity with Medicaid managed care, CMS EQR protocols, state quality programs, or managed care operations.
• Ability to assess how system limitations, data quality issues, and process deficiencies affect regulatory reporting and broader quality oversight activities.
• Strong analytical, problem-solving, technical writing, and evidence-documentation skills.
• Ability to work independently, manage competing priorities, and deliver high-quality technical assessments within established timelines.

Work Arrangement and Contract Details

• Contract Duration: Long-term contract with potential extension options.
• Work Location: Fully remote.
• Geographic Reference: Easton, Maryland.
• Travel Requirements: Travel to designated client or assessment sites may be required.
• Travel Expenses: Travel to sites is not expensed or reimbursed.

Ideal Candidate

The ideal candidate is a detail-oriented healthcare quality and information systems professional who can independently assess complex data environments, evaluate the reliability of performance measures, identify control weaknesses, and translate technical findings into clear, evidence-based recommendations. Experience with Medicaid managed care and CMS External Quality Review requirements is highly desirable.

Qualified candidates with relevant experience in healthcare auditing, information systems assessments, data analytics, or performance measure validation are encouraged to apply.

Our partner has areas for professional growth within a collaborative working environment!!

Company Description

Our partner has areas for professional growth within a collaborative working environment!!