Senior Auditor, Healthcare

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform intricate healthcare performance measure validation (PMV) tasks.

• Utilize HEDIS Compliance Audit methodologies and techniques on both HEDIS and non-HEDIS performance measures in alignment with technical specifications, contractual obligations, and CMS EQR Protocol 2.

• Analyze information systems, data integrity, measure calculation processes, source code, programming logic, medical record review processes, and reported performance measure outcomes.

• Lead and execute HEDIS compliance audits and performance measure validation tasks.

• Conduct assessments of information systems and evaluate systems and processes that contribute to performance measure calculation and reporting.

• Review data sources including enrollment, claims/encounters, provider, pharmacy, laboratory, medical records, supplemental, vendor, and others.

• Examine source code, programming logic, data mapping, measure workflows, and calculation methodologies.

• Validate denominator, numerator, exclusions, eligibility, continuous enrollment, clinical coding, sampling, and measure-specific criteria.

• Carry out primary source verification and record-level testing.

• Review medical record evaluation processes, abstraction methods, sampling, and quality control measures.

• Oversee both virtual and onsite audit activities and engage with client personnel through interviews.

• Identify audit findings, evaluate their impact on measure validity, and formulate evidence-based conclusions and recommendations.

• Prepare and review audit workpapers, validation tools, findings, and reports for clients.

• Offer senior-level reviews, technical guidance, and mentoring to auditors and project team members.

• Communicate technical findings to clients, state Medicaid agencies, internal leadership, and stakeholders.

• Facilitate the ongoing enhancement of audit methodologies, tools, workpapers, and reporting processes.

• Stay updated on HEDIS requirements, CMS EQR protocols, CMS Core Set specifications, and performance measurement standards.

⛳️ Requirements

• Bachelor’s degree in healthcare administration, public health, health information management, nursing, information systems, statistics, data analytics, or a comparable field.

• Extensive experience in HEDIS compliance auditing, healthcare performance measurement, performance measure validation, healthcare data validation, or a related discipline.

• Proven ability to interpret and apply intricate performance measure specifications.

• Experience assessing healthcare information systems, data flows, and data employed for performance measure reporting.

• Proficiency in reviewing source code, programming logic, or measure calculation methodologies, either directly or in collaboration with technical teams.

• Demonstrated experience in conducting audits, developing findings, documenting supporting evidence, and conveying results to clients and stakeholders.

• Proven skill in leading complex audit activities and providing technical guidance to other personnel.

• Preferred: experience with NCQA HEDIS Compliance Audits; performance measure validation according to CMS EQR Protocol 2; Medicaid and/or CHIP managed care programs; CMS Core Set, state-defined, or other non-HEDIS performance measures; information systems evaluations, primary source verification, medical record review validation, and source code review; proficiency in SQL, SAS, Python, or similar data-query or programming tools.

• Advanced understanding of HEDIS performance measurement and audit principles.

• Familiarity with CMS EQR performance measure validation standards and methods.

• Strong comprehension of healthcare information systems, data flows, and performance measure calculation processes.

• Excellent analytical, investigative, and problem-solving abilities.

• Capability to interpret technical specifications and convert them into efficient audit processes.

• Sound professional judgment in evaluating audit evidence and assessing the relevance of findings.

• Strong written, verbal, and interpersonal communication abilities.

• Ability to produce clear, concise, and defensible technical documentation.

• Capacity to manage various priorities and adhere to contractual and regulatory deadlines.

• Ability to work autonomously while providing technical leadership and mentorship to other staff members.

🏝️ Benefits

• Comprehensive health insurance plans.

• Retirement savings options with employer contributions.

• Opportunities for professional development and continuing education.

• Flexible work arrangements and a supportive work environment.