Quality Assurance Coordinator (HEDIS)

Job Description

Job Description

INTRODUCTION:

Central Neighborhood Health Foundation is a Federally Qualified Healthcare Center committed to the Triple Aim as described by the Institute for Healthcare Improvement. Improving the US Health Care System requires simultaneous pursuit of three aims: 1) improving the experience of care, 2) improving the health of populations and 3) reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an "integrator") that accepts responsibility for all three aims for that population.

SUMMARY:

Under the direction of the Quality Assurance Manager, the HEDIS Coordinator is responsible for coordinating activities that support the collection, validation, analysis, and reporting of Healthcare Effectiveness Data and Information Set (HEDIS) measures. This position performs a variety of functions to ensure the accuracy, completeness, and integrity of HEDIS data through detailed investigation, auditing, data validation, and identification of quality improvement opportunities.

The HEDIS Coordinator collaborates with internal departments, providers, and health plan partners to monitor HEDIS performance, resolve data discrepancies, and support medical record retrieval, abstraction, and submission processes. This role assists in maintaining compliance with HEDIS specifications, regulatory requirements, and organizational quality initiatives by analyzing performance trends, identifying gaps in care, and contributing to process improvement efforts that enhance quality outcomes and member care.

The HEDIS Coordinator demonstrates strong analytical, organizational, and communication skills while managing multiple priorities in a fast-paced environment and maintaining confidentiality in accordance with HIPAA and organizational policies.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Coordinate HEDIS activities throughout the measurement year to support accurate,timely, and compliant data collection, validation, reporting, and submission.

• Monitor HEDIS project timelines and provide regular status updates to the Quality Assurance Manager and leadership regarding project progress, barriers, and outcomes.

• Develop, implement, and maintain action plans designed to improve HEDIS performance and quality measure outcomes.

• Generate, analyze, and evaluate HEDIS reports to identify gaps in care, member compliance, provider performance, and opportunities for quality improvement.

• Perform data validation, auditing, and investigation activities to ensure the accuracy, completeness, and integrity of HEDIS data and supporting documentation.

• Research and resolve data discrepancies by collaborating with providers, health plans, vendors, and internal departments.

• Coordinate medical record retrieval, chart review, abstraction, and documentation activities to support HEDIS reporting requirements.

• Maintain complete and accurate documentation of audits, investigations, corrective actions, and supporting evidence for all HEDIS-related activities.

• Monitor vendor performance and project deliverables to ensure quality standards and reporting deadlines are met.

• Assist in developing and implementing interventions to improve preventive care utilization and close identified gaps in care.

• Collaborate with Clinical, Population Health, Provider Relations, Health Information Management, and Information Technology teams to improve data accuracy and measure performance.

• Support provider outreach by educating provider offices on HEDIS measures, documentation requirements, coding guidelines, and best practices that improve quality scores.

• Analyze HEDIS performance trends and prepare reports, dashboards, and presentations for leadership, health plans, and quality committees.

• Ensure compliance with NCQA HEDIS Technical Specifications, CMS requirements, state and federal regulations, organizational policies, and contractual reporting requirements.

• Participate in internal and external audits and assist with the preparation of documentation requested by regulatory agencies and health plan partners.

• Identify process improvement opportunities and recommend workflow enhancements that increase efficiency, data accuracy, and quality outcomes.

• Maintain the confidentiality and security of protected health information (PHI) in accordance with HIPAA and organizational policies.

• Participate in departmental meetings, quality improvement initiatives, training programs, and continuing education related to HEDIS, quality improvement, and regulatory requirements.

• Perform other duties as assigned to support departmental and organizational quality initiatives.

QUALIFICATION REQUIREMENTS:

To perform this job successfully an individual must be able to perform each essential duty, satisfactorily. Requirements listed below are representative of the knowledge, skill and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE:

• Bachelor’s degree in Healthcare Administration, Public Health, Nursing, Health Information Management, Business Administration, or a related field preferred. An equivalent combination of education and relevant experience may be considered.

• Minimum of three (3) years of experience in healthcare quality improvement, managed care, health information management, medical records, quality assurance, or a related healthcare field preferred.

• Minimum of one (1) year of experience working with HEDIS, NCQA quality measures, CMS quality programs, or other healthcare quality reporting initiatives preferred.

• Experience with medical record review, chart abstraction, clinical documentation, coding validation, or healthcare data analysis preferred.

• Knowledge of HEDIS Technical Specifications, quality improvement methodologies, and healthcare regulatory requirements preferred.

• Experience using electronic health records (EHR), population health platforms, data reporting systems, and healthcare analytics tools preferred.

• Experience collaborating with providers, health plans, and multidisciplinary teams to improve quality outcomes is highly desirable.

• Certification in Healthcare Quality (CPHQ), Certified Professional in Health Care Quality, or other quality-related certification is preferred but not required.

NECESSARY SKILLS:

• Strong analytical, critical thinking, and problem-solving skills with the ability to interpret healthcare quality data and identify trends.

• Knowledge of HEDIS measures, NCQA standards, CMS quality programs, and healthcare quality improvement principles.

• Ability to analyze data, identify gaps in care, and recommend evidence-based improvement strategies.

• Proficient in conducting audits, validating data, and maintaining accurate documentation to ensure regulatory compliance.

• Excellent organizational and time management skills with the ability to manage multiple priorities and meet strict deadlines.

• Strong written and verbal communication skills with the ability to present findings clearly and professionally.

• Ability to build collaborative relationships with providers, health plans, vendors, and internal departments.

• Proficiency with Microsoft Office Suite, including Excel (advanced functions, formulas, pivot tables, and data analysis), Word, Outlook, and PowerPoint.

• Experience working with Electronic Health Records (EHRs), population health platforms, reporting databases, and quality management systems.

• Knowledge of healthcare coding, clinical documentation, and medical terminology preferred.

• Ability to work independently while contributing effectively as a member of a multidisciplinary team.

• Strong attention to detail with a high level of accuracy when reviewing clinical documentation and quality data.

• Demonstrated project coordination, process improvement, and organizational skills.

• Working knowledge of HIPAA privacy regulations and the ability to maintain the confidentiality of Protected Health Information (PHI).

• Proficiency in Lean, Six Sigma, PDSA, or other quality improvement methodologies is desirable.

Policy

Punctual and regular attendance is an essential responsibility of each employee at CNHF. Employees are expected to report to work as scheduled, on time and prepared to start working. Employees also are expected to remain at work for their entire work schedule. Late arrival, early departure or other absences from scheduled hours are disruptive and must be avoided.

This policy does not apply to absences covered by the Family and Medical Leave Act (FMLA) or leave provided as a reasonable accommodation under the Americans with Disabilities Act (ADA). These exceptions are described in separate policies.

WORK ENVIRONMENT

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 qualified individuals with disabilities to perform the essential functions. Variations in conditions may occur under certain circumstances.

CONFIDENTIALITY

Maintains patient, employee, and Foundation confidentiality at all times, discussing patient or employee business only with appropriate parties who have a bona fide need to know; and communicating only the minimum amount of information necessary with respect to protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

1. AGREEMENT AND ACCEPTANCE

2. I HAVE READ THE ABOVE JOB DESCRIPTION AND FULLY UNDERSTAND THE REQUIREMENTS SET FORTH AND WILL PERFORM ALL DUTIES AND RESPONSIBILITIES TO THE BEST OF MY ABILITY.