Quality Audit Manager - Healthcare
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).
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