HEDIS Audit Quality Manager (State and NCQA)

Elevance Health; Waukesha (WI); Hybrid; USD 99,000 - 163,000; Full time

Benefits offered by this job

Hybrid work model

Benefits package including 401k

Job summary

Elevance Health is seeking a HEDIS Audit Quality Manager to lead all HEDIS audit activities across lines of business and regulatory bodies. You will oversee audit processes, coordinate with internal teams and health plans to ensure timely submissions to NCQA, CMS, and state regulators.

The role requires a BA/BS in a healthcare field and at least 3 years in healthcare QA/QI, with strong knowledge of NCQA HEDIS guidelines. Hybrid in-office 1-2 days per week; travel not specified.

Qualifications

• BA/BS in a health care field and minimum of 3 years healthcare-related experience, plus 3 years in QA/QI
• Strong knowledge of NCQA HEDIS audit guidelines and processes
• Experience leading HEDIS audits across multiple lines of business and with Medicaid/State Auditors preferred

Responsibilities

• Interfaces with clients, quality committees, and departments for HEDIS submissions
• Manages overall HEDIS audit processes and resources
• Interprets HEDIS guidelines and manages submission activities
• Leads audit project plans with deliverables and timelines
• Performs data analysis and reports improvements to quality committees
• Coordinates with health plans on state audits and reporting requirements

Skills

HEDIS auditing

QA/QI

NCQA guidelines

Project management

Stakeholder management

Education

BA/BS in healthcare

3+ years healthcare QA/QI

Job description

HEDIS Audit Quality Manager (State and NCQA Audits)

Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office .

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The HEDIS Audit Quality Manager is responsible for managing all HEDIS Audit activities for all lines of business, region of the company, market, and/or enterprise wide which are necessary for submission of audited HEDIS and CAHPS results to NCQA, CMS, and State Regulatory Agencies.

Primary duties may include, but are not limited to:

• Interfaces with internal and external clients, quality committees, and departments in the review of HEDIS submissions and requirements.
• Manages the overall HEDIS audit processes and resources required to successfully lead the team.
• Evaluates, interprets and summarizes HEDIS audit guidelines and manages the process for HEDIS submission activities.
• Identifies appropriate resources and accountabilities for project teams involved with the HEDIS audit.
• Conducts the ongoing evaluation and interpretation of NCQA, CMA, and State HEDIS requirements to ensure compliance through reporting and measurement studies/ methodologies.
• Serves as expert resource to quality committees and business owners across the organization.
• Leads and provides oversight of quality studies/projects.
• Facilitates project management and develops comprehensive HEDIS audit work plans by establishing deliverables, accountabilities, and timelines.
• Performs quantitative and qualitative analysis of quality related data and reports activities, improvements, and recommendations to the quality committee.
• Coordinates with health plans on state specific audits and reporting requirements.

Minimum Requirements

• Requires a BA/BS in a health care field and minimum of 3 years healthcare-related experience, in addition, minimum of 3 years’ experience in a QA/QI related position; or any combination of education and experience, which would provide an equivalent background.

Preferred Qualifications

• Extensive experience managing the overall HEDIS audit processes for all lines of business with Medicaid State Auditors and/or National Auditors strongly preferred.
• Strong knowledge of the NCQA HEDIS audit guidelines and processes used to submit HEDIS to the National and State HEDIS auditors strongly preferred.
• Experience creating and managing a large project plan that identifies appropriate resources and accountabilities for project teams involved with the HEDIS audit.
• Experience leading mock interviews with internal departments to prepare for the external HEDIS Audits.
• HEDIS audit experience preferred.
• Experience with Medicaid preferred.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $99,372 to $163,254

Locations: California; Illinois; Massachusetts; Maryland; Minnesota; New Jersey

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration https://info.flclearinghouse.com/.