Clinical Quality Specialist

The specialist works collaboratively with providers, vendors, and internal departments to ensure compliance with NCQA, CMS, state, and organizational requirements while supporting data integrity and audit readiness.

Duties & Responsibilities

• Performs HEDIS medical record review, abstraction, data entry and validation activities in accordance with NCQA guidelines and organizational policies.
• Reviews and validates clinical documentation and coding from electronic medical records (EMRs), provider records, vendors, and other clinical data sources.
• Ensures the accuracy, completeness, and integrity of HEDIS data used for regulatory reporting and quality improvement initiatives.
• Ensures compliance with NCQA supplemental data standards.
• Identifies and resolves data discrepancies, documentation gaps, and data integrity issues.
• Participates in internal and external HEDIS audits and support audit readiness activities.
• Maintains compliance with NCQA, CMS, state, and organizational standards and requirements.
• Communicates with provider offices, vendors, and internal departments to obtain medical records and clarify documentation requirements.
• Prepares and maintains audit logs, tracking documentation, productivity reports, and compliance findings.
• Supports continuous quality improvement and process enhancement initiatives related to HEDIS operations.
• Collaborates with Quality Improvement, Analytics, Coding, and operational teams to support departmental goals and regulatory requirements.
• Additional duties as necessary and as directed

Minimum Qualifications

• Bachelor’s degree from an accredited college or university in Nursing, Public Health, Health Administration, Healthcare Management, Public Policy, or a related field required.
• Knowledge of MS Office Applications

Experience

• Minimum of one (1) year of experience in healthcare quality, HEDIS operations, medical record review, data abstraction, or healthcare analytics required.

Knowledge, Skills, and Abilities

• Working knowledge of HEDIS measures, clinical documentation standards, and healthcare quality programs.
• Knowledge of ICD-10, CPT, HCPCS coding, and medical terminology.
• Familiarity with EMR systems, data abstraction tools, and healthcare databases.
• Strong analytical, organizational, and problem-solving skills.
• Strong attention to detail with the ability to manage multiple priorities in a fast-paced environment.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office Suite, including Excel and Outlook.
• Ability to work independently and meet strict deadlines during HEDIS season.

Preferred Qualifications

• Background in health care or managed care. This can include work experience and/or education.
• Experience with a health plan's quality improvement/management department
• Two (2) or more years of experience in Managed Care, Health Insurance, or Quality Improvement.
• Knowledge of NCQA HEDIS specifications, STAR, and QARR quality programs.
• Prior experience with HEDIS abstraction, chart review, audit support, or medical record validation.
• Experience working with provider outreach and cross-functional teams.
• Experience supporting regulatory audits and quality reporting initiatives