HEDIS Quality Improvement

Ultimate Staffing Services is actively seeking a highly skilled HEDIS Quality Improvement Specialist to join a dedicated Quality Management team in Morrisville, North Carolina (hybrid). This role involves serving as a subject matter expert in HEDIS, supporting quality improvement initiatives, medical record review, data validation, audit readiness, and regulatory compliance. The ideal candidate will have a robust background in HEDIS, NCQA standards, medical record abstraction, and healthcare quality improvement, along with experience working within Medicaid and/or managed care environments.

• Serve as a subject matter expert (SME) for NCQA HEDIS measures, including Hybrid, Administrative, and ECDS measures.
• Coordinate and support HEDIS projects through planning, execution, monitoring, and completion.
• Monitor project timelines, deliverables, and audit readiness activities.
• Identify risks and implement solutions to ensure successful project outcomes.
• Conduct medical record abstraction and validation activities.
• Perform quality assurance reviews to ensure accuracy and compliance with HEDIS specifications.
• Support Supplemental Data Validation Audits (SDVA), Medical Record Review Validation (MRRV), and other audit-related processes.
• Assist with primary source verification and data integrity initiatives.
• Analyze HEDIS performance data and identify opportunities for improvement.
• Assist with gap-in-care analysis and quality improvement initiatives.
• Develop reports and recommendations that support organizational quality goals.
• Collaborate with cross-functional teams to implement performance improvement strategies.
• Develop and maintain HEDIS training materials, tip sheets, documentation guides, and educational resources.
• Deliver HEDIS measure training and competency assessments.
• Provide ongoing education and support to internal teams and stakeholders regarding HEDIS requirements and best practices.
  
  

Required Education & Credentials

• Associate Degree in Nursing and active RN licensure
• Licensed Practical Nurse (LPN) license
• Graduation from an accredited coding program with Certified Professional Coder (CPC) certification

Required Experience

• 3 years of HEDIS clinical quality and process improvement experience for RN candidates OR
• 5 years of HEDIS clinical quality and process improvement experience for LPN or CPC candidates
• Experience with NCQA HEDIS Technical Specifications
• Experience with medical record abstraction and quality review
• Knowledge of HEDIS data collection and reporting requirements
• Experience supporting healthcare quality improvement initiatives
• Familiarity with Value Set Directory (VSD)
• Experience working with Medicaid populations

Preferred Qualifications

• Managed care or health plan experience
• NCQA audit experience
• Experience with Supplemental Data Validation Audits (SDVA)
• Healthcare analytics and reporting experience
• Lean, Six Sigma, Kaizen, or other quality improvement methodologies
• Experience developing and delivering training programs
  
  

Monday - Friday, 1st shift

• Medical
• Dental
• Vision
• Pharmacy
  
  

Salary Range: $35 - $40 per hour

This is an excellent opportunity for a healthcare quality professional who enjoys combining clinical expertise, analytics, compliance, and quality improvement to drive meaningful outcomes for members and providers. You'll work alongside a collaborative team dedicated to improving healthcare quality and performance across the communities served.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, Los Angeles County Fair Chance Ordinance, and San Francisco Fair Chance Ordinance.