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Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Consultant, HEDIS - Medicare Stars and Public Reporting - Georgia Region

Location: Atlanta, GA Additional Locations:
Job Number: 741262 Date posted: 10/05/2018

The Consultant HEDIS, Medicare Stars and Public Reporting will collaborate with executive sponsors, business owners and other members of the quality team to develop, plan and drive HEDIS and Star strategy. The Consultant is responsible for the strategic development of the NCQA HEDIS and Medicare Star programs in collaboration with the Quality team.  The Consultant is the point of contact for Program Office (including National Market Research) and will function as one of the regional leads. The Consultant will analyze data from multiple sources and create and present reports to leadership.  As the subject matter expert for the region the Consultant will work with the quality team to develop recommendations and strategies for achieving leading practices in Star and HEDIS metrics (e.g., MERIT).  The Consultant will continually monitor quality ratings and facilitate discussions of changes in measurement specifications, measurement additions or deletions and benchmarks/cut points, with the team while continually projecting impacts on performance and keeping leadership abreast of findings. The Consultant is responsible for responding to information requests and coordination of formal and ad hoc responses related to public reporting and requests for information related to HEDIS, Stars, QRS, CAHPS, METEOR, QHP, HOS Annual Incentive Plans and MOU's.  He/she will assist with audits and validation of data as requested. The consultant will work with the Quality Team in providing strategic analysis of Performance Guarantees and OPM Corrective Action Plans). The Consultant must have strong analytical skills and have the ability to communicate complex data and information in a simple and compelling way so that leadership can understand possible actions to take based on the data presented.  He/she must be able to translate business strategy into operational goals to initiate success and understand the technical specifications behind HEDIS, Stars, CAHPS, etc.

Essential Responsibilities:

  • Operationally responsible for all things related to HEDIS and Star programs as well as all public reporting, national reporting and regional reporting.  Responsible for reporting, coordination and responding to quality related information requests, compiling reports, and assisting with the development of strategies that will result in Medicare 5 Star and HEDIS 90th percentile targets.

  • Partner and develop strong collaborative relationships with TSPMG, operations, and other members of the quality team to develop strategies and initiatives that ensure improvements in HEDIS, Star, and other metrics, guarantees, ratings and scores.  Works closely with the NCQA/HEDIS Administrator and Program Director of Medicare Strategy.  Serves as subject matter expert for HEDIS and Stars, acts as a consultant to the region and department.

  • Exhibits strong analytic skills, understands and uses data to facilitate decision making. Communicates complex data and changes in scores and cut points in a simple easy to understand and compelling way.

  • Extracts data from various locations and databases to create reports.  Continually analyzes data quality and integrity and shares findings and strategic recommendations.  

  • Partners across national and regional leaders to ensure representation of GA Region and understanding of practices and policies nationally.

  • Maintains active involvement in public comment periods and strategic planning for all metric related activities and communicates information to key stakeholders.

  • Must possess strong project management skills.

  • Basic Qualifications:


  • Minimum 6 (six) year's experience in roles such as healthcare operations or management, healthcare project management, program management, data analytics, public health or related fields.

  • Education

  • Bachelor's degree OR four (4) years of experience in a directly related field.

  • High School Diploma or General Education Development (GED) required.

  • License, Certification, Registration

  • N/A

  • Additional Requirements:

  • In-depth knowledge and understanding of Medicare Star and HEDIS technical specification and strategies.

  • Knowledge of health care delivery operations required

  • Demonstrated strong interpersonal/communication skills.

  • Strong presentation, project management and problem-solving skills required.

  • Ability to lead through influence.

  • Strong verbal and written communication skills and presentation skills required.

  • Demonstrated understanding of HEDIS, Medicare Stars, NCQA or if no exposure beforehand, demonstrated ability to understand and apply detailed industry specification to the business function.

  • Self-starter, organized, able to work with minimal supervision, results oriented team-oriented approach to problem solving.

  • Good at creative problem solving and decision making, has an eye for detail.

  • Ability to manage moderately complex situations and programs.

  • Ability to lead changes to modify or change methodology as required to redirect activities to attain objectives.

  • Monitor performance metrics against goals and targets. Document and present outcome results through operational reports, outcomes studies, presentations and publications.

  • Project management, performance improvement, administration or operations experience desired.

  • Expert understanding of Stars and HEDIS.

  • Project management experience.

  • Preferred Qualifications:

  • Prefer experience in a multi-faceted health care system and a multi provider setting.

  • Master's degree in accounting, finance, business, health care or public administration OR six (6) years of experience in a directly related field.
  • Primary Location: Georgia,Atlanta,Regional Office - 9 Piedmont 9 Piedmont Center 34 Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Individual Contributor Job Category: QA / UR / Case Management Department: Metrics Management Travel: Yes, 25 % of the Time

    About QA, Ur & Case Management Careers

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    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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