hsag - Senior Auditor (Healthcare)
Requirements
• Bachelor's degree in healthcare administration, public health, health information management, nursing, information systems, statistics, data analytics, or a related field. • Demonstrated ability to interpret and apply complex performance measure specifications. • Experience evaluating healthcare information systems, data flows, and data used for performance measure reporting. • Experience reviewing source code, programming logic, or measure calculation methodologies, directly or in collaboration with technical staff. • Experience conducting audits, developing findings, documenting supporting evidence, and communicating results to clients and stakeholders. • Demonstrated ability to lead complex audit activities and provide technical guidance to other staff. • Experience conducting NCQA HEDIS Compliance Audits. • Experience conducting performance measure validation under CMS EQR Protocol 2. • Experience with Medicaid and/or CHIP managed care programs. • Experience validating CMS Core Set, state-defined, or other non-HEDIS performance measures. • Experience with information systems assessments, primary source verification, medical record review validation, and source code review. • Familiarity with SQL, SAS, Python, or similar data-query or programming tools. • Advanced knowledge of HEDIS performance measurement and audit concepts. • Knowledge of CMS EQR performance measure validation requirements and methodologies. • Ability to apply established HEDIS audit techniques to HEDIS and non-HEDIS performance measures. • Strong understanding of healthcare information systems, data flows, and performance measure calculation processes. • Strong analytical, investigative, and problem-solving skills. • Ability to interpret technical specifications and translate them into effective audit procedures. • Sound professional judgment in evaluating audit evidence and determining the significance of findings. • Strong written, verbal, and interpersonal communication skills. • Ability to prepare clear, concise, and defensible technical documentation. • Ability to manage multiple priorities and meet contractual and regulatory deadlines. • Ability to work independently while providing technical leadership and mentoring to other staff. • Work Environment • The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Responsibilities
• Lead and conduct HEDIS compliance audit and performance measure validation activities. • Conduct information systems assessments and evaluate systems and processes supporting performance measure calculation and reporting. • Assess the accuracy, completeness, and integration of enrollment, claims/encounter, provider, pharmacy, laboratory, medical record, supplemental, vendor, and other applicable data sources. • Review source code, programming logic, data mapping, measure workflows, and calculation methodologies for compliance with measure specifications. • Validate denominator, numerator, exclusions, eligibility, continuous enrollment, clinical coding, sampling, and other measure-specific requirements. • Conduct primary source verification and record-level testing to verify the accuracy of source data and reported results. • Evaluate medical record review processes, abstraction methodologies, sampling, and quality-control procedures, as applicable. • Lead virtual and onsite audit activities and conduct interviews with client staff responsible for information systems, data management, programming, quality measurement, and reporting. • Identify audit findings, assess their impact on measure validity, and develop clear, evidence-based conclusions and recommendations. • Prepare and review audit workpapers, validation tools, findings, and client-facing reports. • Provide senior-level review and technical guidance to auditors and other project staff. • Communicate complex technical findings effectively to clients, state Medicaid agencies, internal leadership, and other stakeholders. • Support development and continuous improvement of audit methodologies, tools, workpapers, and reporting processes. • Maintain current knowledge of HEDIS requirements, CMS EQR protocols, CMS Core Set specifications, and other applicable performance measurement standards. • HSAG is an EEO Employer of Veterans protected under Section 4212. • If you have special needs and require assistance completing our employment application process, please feel free to contact us. • EOE M/F/Veteran/Disability
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