Director of HEDIS Operations

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Position Summary:

The Director of HEDIS Operations is a highly visible, senior, strategic leadership role reporting to the Associate Chief Medical Officer (ACMO), Quality & Transformation. The Director oversees and manages the functions of HEDIS operations, with a focus on efficient and accurate chart abstraction for the prospective and retrospective campaigns and supplemental data, with the goal of maximizing HEDIS performance and ensuring high-fidelity processes. This position will require a strong background in the understanding of HEDIS measures, clinical documentation in the EMR, HEDIS compliance audits and personnel management. This role requires a closer partnership with IT/data/reporting teams and HEDIS software vendor; as such, requires a leader that is adept at working with EMRs, analytical skills in synthesizing information from data, and communicating business requirements to IT. In addition, the HEDIS Director role involves a significant amount of cross-functional collaboration with the Provider Engagement team, Quality Performance team, and other departmental stakeholders.

The Director in this role will be responsible for the following:

• Work with the ACMO and Directors of Quality Performance for all LOBs to define the HEDIS strategy for the organization, including annual and long-term strategic plans for performance improvement.
• Flawlessly execute the defined strategy to deliver the set annual performance goals of the health plan.
• Successfully oversee the annual HEDIS audit, including coordination with all key stakeholders for preparedness and document collection, and maintains year-round communication with HEDIS Auditor.
• Stay abreast of NCQA updates and other regulators to HEDIS/Quality measurement program-measure specifications, data collection and reporting methodology, audit guidelines, etc-- and lead the organization's readiness for such changes.
• Drive HEDIS workflow process improvement for prospective and retrospective chart chase, and oversee year-round primary source verification for supplemental data.
• Demonstrates strong supervisory competencies in oversight of HEDIS Operations team, which includes but is not limited to Clinical Quality Nurses, and HEDIS Coders, and provides clear direction and accountability. The HEDIS Director will be responsible for overseeing a large team of employed and contracted nursing personnel, including all aspects of building and maintaining a high-performing team such as recruitment/onboarding, performance monitoring, team development and training activities.
• Oversees financial management of a high-impact cost center with a multi-million dollar budget, ensuring budget alignment, cost optimization, and operational efficiency while supporting organizational goals
• Builds relationships with and leads cross-functional teams to drive quality performance initiatives and best practices by promoting innovation, strategy development, and implementation excellence
• Chairs, facilitates, and/or presents at Executive-level committee meetings related to Quality, effectively communicating performance progress, new initiatives needed for higher performance, organizational barriers, and expectations of results
• Effectively manages vendors and holds them accountable for high performance based on the strong operational knowledge of the health plan
• Understands overall organizational processes, operations and challenges that may impact HEDIS operations and provides leadership with visibility on the potential impacts (positive or negative) along with the mitigation efforts.
• Drives positive culture transformation and corporate-wide awareness of HEDIS through education, communication, and employee engagement

Qualifications:

• Bachelor's degree in health administration or a related field required. Master's degree in health administration or a related field strongly preferred.
• 7- 10+ years of progressively responsible related experience in Medicare and Medicaid including 3-5 years of management experience.
• Minimum 3-5 years of managed care experience, specifically in government programs, is required
• Experience with health plan operations inclusive of quality principles and standards such as accreditation, HEDIS requirements and submissions, Medicare STARS, compliance, and quality of care standards.
• Robust knowledge and strong experience with clinical informatics/clinical data and EMR documentation required.
• Familiarity with clinical terminology standards (ICD/snomed, DRG, NDC, LOINC, CPT/HCPCS) and messaging standards (FHIR, HL7)
• Familiarity with quality measurement and reporting standards (HEDIS, eCQM/dQM, ECDS)
• Strong knowledge and understanding as well as ability to interpret Federal and State regulations inclusive of CMS and NCQA regulatory requirements
• CPHQ or Lean Six Sigma or Clinical Informatics certification preferred

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