Clinical Quality Specialist

The Clinical Quality Specialist is responsible for performing Healthcare Effectiveness Data and Information Set (HEDIS) medical record review, supplemental data validation, data abstraction, and clinical data quality activities using internal and external clinical data sources. This role supports the accurate, timely, and compliant collection of clinical data for HEDIS reporting, regulatory submissions, and quality improvement initiatives. The specialist works collaboratively with providers, vendors, and internal departments to ensure compliance with NCQA, CMS, state, and organizational requirements while supporting data integrity and audit readiness. This position follows a hybrid work model consisting of remote and office-based work. Office location: 100 Church Street, New York, NY Duties & Responsibilities Performs HEDIS medical record review, abstraction, data entry and validation activities in accordance with NCQA guidelines and organizational policies. Reviews and validates clinical documentation and coding from electronic medical records (EMRs), provider records, vendors, and other clinical data sources. Ensures the accuracy, completeness, and integrity of HEDIS data used for regulatory reporting and quality improvement initiatives. Ensures compliance with NCQA supplemental data standards. Identifies and resolves data discrepancies, documentation gaps, and data integrity issues. Participates in internal and external HEDIS audits and support audit readiness activities. Maintains compliance with NCQA, CMS, state, and organizational standards and requirements. Communicates with provider offices, vendors, and internal departments to obtain medical records and clarify documentation requirements. Prepares and maintains audit logs, tracking documentation, productivity reports, and compliance findings. Supports continuous quality improvement and process enhancement initiatives related to HEDIS operations. Collaborates with Quality Improvement, Analytics, Coding, and operational teams to support departmental goals and regulatory requirements. Additional duties as necessary and as directed Minimum Qualifications Bachelor’s degree from an accredited college or university in Nursing, Public Health, Health Administration, Healthcare Management, Public Policy, or a related field required. Knowledge of MS Office Applications Experience: Minimum of one (1) year of experience in healthcare quality, HEDIS operations, medical record review, data abstraction, or healthcare analytics required. Knowledge, Skills, and Abilities Working knowledge of HEDIS measures, clinical documentation standards, and healthcare quality programs. Knowledge of ICD-10, CPT, HCPCS coding, and medical terminology. Familiarity with EMR systems, data abstraction tools, and healthcare databases. Strong analytical, organizational, and problem-solving skills. Strong attention to detail with the ability to manage multiple priorities in a fast-paced environment. Excellent verbal and written communication skills. Proficiency in Microsoft Office Suite, including Excel and Outlook. Ability to work independently and meet strict deadlines during HEDIS season. Preferred Qualifications Background in health care or managed care. This can include work experience and/or education. Experience with a health plan's quality improvement/management department Two (2) or more years of experience in Managed Care, Health Insurance, or Quality Improvement. Knowledge of NCQA HEDIS specifications, STAR, and QARR quality programs. Prior experience with HEDIS abstraction, chart review, audit support, or medical record validation. Experience working with provider outreach and cross-functional teams. Experience supporting regulatory audits and quality reporting initiatives. Compliance & Regulatory Responsibilities Noted above License/Certification: N/A HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to View email address on click.appcast.io or calling View phone number on click.appcast.io . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620 All Other Locations (within approved locations): $61,300 - $91,120 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role. Healthfirst is New York’s largest not-for-profit health insurer offering it’s nearly 1.7 million members access to high-quality, affordable healthcare. As part of the community for nearly 30 years, Healthfirst’s unique advantage is rooted in its belief that good health doesn’t start in a doctor’s office. The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well-being. This value-based care model is the foundation of the company’s sustained growth in one of the most dynamic markets in the country. So, if you are passionate about what you do and want to work for a company that is focused on the future and dedicated to making a difference in people’s lives, then Healthfirst is for you. #J-18808-Ljbffr