Full-Time Quality Audit Manager

Role and Responsibilities:

• Conduct detailed audits of healthcare readmission data to ensure compliance with HEDIS measures and NCQA guidelines.
• Validate the accuracy and completeness of data used for HEDIS reporting, focusing on readmission metrics.
• Identify discrepancies or inconsistencies in data, and work with relevant teams to correct and update records
• Utilize SQL to extract, manipulate, and analyze large datasets related to hospital readmissions.
• Develop and generate reports on readmission trends, performance metrics, and compliance with HEDIS standards.
• Provide actionable insights and recommendations to improve readmission rates and overall healthcare quality
• Ensure that all HEDIS audit activities are conducted in accordance with NCQA guidelines and organizational policies.
• Collaborate with the quality improvement team to identify opportunities for enhancing audit processes and healthcare outcomes.
• Participate in NCQA HEDIS audits, preparing necessary documentation and data submissions

Candidate Profile:

Required Qualification and Skills:

• Strong experience on analysis of Medicare claims based on ICD Codes, Risk factors and Medical Adherence, Proc Codes, LOINC Codes and others.
• Minimum of 3-5 years of experience in healthcare analytics, quality improvement, or data auditing, with a focus on HEDIS and NCQA standards.
• Proven experience working with HEDIS measures, specifically related to readmissions.
• Strong proficiency in SQL for data extraction, manipulation, and analysis.
• Experience with healthcare data systems and tools (e.g., EHRs, claims databases).
• Familiarity with data visualization tools (e.g., Tableau, Power BI) is a plus
• In-depth understanding of HEDIS measures, NCQA guidelines, and healthcare quality improvement processes.
• Knowledge of healthcare regulations and compliance standards (e.g., HIPAA).