HEDIS Quality Improvement Lead- Hedis

POSITION SUMMARY

The Healthcare Effectiveness Data and Information Set (HEDIS) Quality Improvement Lead closely

collaborates with other Health First Health Plans (HFHP) departments and Health First entities to

ensure regulatory compliance, support and improve Centers for Medicare and Medicaid Services

(CMS) STARS programs, National Committee for Quality Assurance (NCQA) Accreditation and other

Value Capture clinical quality improvement programs. The HEDIS Quality Improvement Lead drives

HEDIS quality and reliability through coaching Associates on critical thinking and High Reliability

Organization (HRO) principles, while supporting HEDIS leadership through delegated data analysis,

reporting, and regulatory preparation related to HEDIS Operations’ data, databases, and reporting

policies and procedures for HEDIS Operations. The HEDIS Quality Improvement Lead assists with

HEDIS department regulatory submissions, including the annual NCQA HEDIS Roadmap, NCQA

HEDIS annual audit and monthly HEDIS quality improvement (QI) program monitoring and reporting, as

well as with Value Capture quality programs involved in the care of HFHP membership.

PRIMARY ACCOUNTABILITIES

1. Provides daily support to HEDIS team (Associate Analysts, Analysts, Senior Analysts) on critical

thinking, error prevention, and HRO behaviors (e.g., side-by-side coaching, reflective

questioning).

2. Monitors HEDIS team performance and processes to identify bottlenecks, error patterns, and

improvement opportunities.

3. Integrates QI and HRO principles into team routines (risk-focused huddles, blameless debriefs)

and delivers micro-trainings.

4. Designs and tests QI solutions (e.g., workflow adjustments, checklists) using Plan-Do-Study-Act

(PDSA) and Root Cause Analysis (RCA).

5. Executes, transforms, and validates multi-source performance dashboards (accuracy,

productivity, initiative impact, etc.), identifying and resolving critical data gaps impacting

measure scores.

6. Conducts high-level analysis of HEDIS gap trends, benchmark comparisons, and overall trend

drivers for HEDIS Leadership review.

7. Performs in-depth data validation, identifying root causes of initial HEDIS metric trend

variances, and develops actionable remediation plans for HEDIS Leadership review.

8. Exercises independent judgment to organize and translate complex data into executive

summaries and visuals.

9. Compiles and organizes documentation for NCQA and CMS submissions (e.g., ROADMAP

support files), ensuring exceptional data governance and data integrity standards.

10. Tracks and maps evidence for standard compliance.

MINIMUM QUALIFICATIONS

• Education: Bachelor’s degree in Healthcare Sciences or Administration, Quality Management,

Business Administration, or a relevant field.

• Work Experience:

o Five (5) years’ experience in quality improvement, data analysis, operations

coordination, clinical quality or a related field.

o Two (2) years’ in leadership or educator role.

• Licensure: None
• Certification: Certified Professional in Healthcare Quality (CPHQ) within one (1) year of start

date and maintained.

• Skills/Knowledge/Abilities:

o Proficiency in health care related applications, Electronic Medical Records (EMRs),

Microsoft Office, and an advanced understanding of database management.

o Adavanced experience with statistical analysis concepts, report generation and auditing.

o Proven coaching and facilitation skills (e.g., training, mentoring or leading projects).

o Ability to organize complex documentation and follow compliance protocols.

o Analytical skills are sufficient to assess and identify variations in data and processes.

o Experience with the application of PDSA, RCA, HRO principles, and process mapping.

o Ability to abstract data, and present data in clear reporting formats to support

comparison and analysis.

o Exceptional interpersonal relationship skills, including proficient communication skills to

translate data and process insights for both analysts and leadership.

o Experience monitoring policies, internal control procedures and operations standards.

PREFERRED QUALIFICATIONS

• Education: Master’s degree in Healthcare Sciences or Administration, Quality Management,

Business Administration, or a relevant field.

• Work Experience: Prior experience in managed care or clinical healthcare setting.
• Licensure: Registered Nurse (RN) licensure in the State of Florida or endorsement.
• Certification: Certified Professional Coder (CPC).
• Skills/Knowledge/Abilities:

o Advanced knowledge base of clinical standards of care, preventive health standards,

HEDIS, NCQA, governing and regulatory agency requirements, and the managed care

industry.

o Experience performing HEDIS ADMIN and hybrid medical record reviews, including

performing HEDIS abstractions/overreads.

o Understanding of NCQA Accreditation and CMS MA/QRS Star program requirements

with experience working through an NCQA HEDIS Annual Audit.

o Required Knowledge/Skills/Abilities experience completed in a managed care or clinical

healthcare setting.

PHYSICAL REQUIREMENTS

• Majority of time involves sitting or standing; occasional walking, bending, and stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low

to moderate noise.

• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined.
• May require travel to various facilities within and beyond county perimeter; may require use of

personal vehicle.

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.