Manager Clinical Quality Data Validation and Governance

Essential Duties And Responsibilities

• Leads governance and oversight of HEDIS clinical supplemental data sources, clinical data validation, medical record review, and supplemental data processes.
• Establishes and maintains data quality standards, validation controls, and audit readiness processes.
• Ensures compliance with NCQA, CMS, state, and organizational requirements.
• Identifies and mitigates data quality, compliance, and reporting risks.
• Supports HEDIS audits, supplemental data reviews, and regulatory reporting activities.

Operations & Performance Management

• Oversees clinical data validation, abstraction, and quality assurance activities.
• Maintains productivity, accuracy, quality metrics, and reporting deadlines.
• Investigates and resolves data discrepancies, documentation gaps, and operational issues.
• Develops and maintains operational reports, dashboards, and performance metrics.
• Manages relationships with vendors, provider organizations, and delegated entities.

Team Leadership

• Supervises, coaches, and develops Clinical Quality Specialists and related staff.
• Manages hiring, onboarding, performance evaluations, and workforce planning activities.
• Establishes productivity, quality, and performance expectations.
• Fosters a culture of accountability, collaboration, and continuous improvement.

Collaboration

• Partners with Clinical IT, Enterprise Delivery Services, DSE, and Operations teams to support organizational quality goals.
• Communicates performance results, audit outcomes, and strategic recommendations to leadership and stakeholders.

Minimum Qualifications

• Education: Bachelor's degree in Nursing, Public Health, Health Administration, Healthcare Management, Health Informatics, or a related field from an accredited institution.
• Experience: Five (5) years of experience in healthcare quality, HEDIS operations, clinical data validation, healthcare analytics, or quality improvement; two (2) years of supervisory or leadership experience.

Knowledge, Skills, And Abilities

• Strong knowledge of NCQA HEDIS, supplemental data standards, STAR, QARR, and regulatory reporting requirements.
• Knowledge of ICD-10, CPT, HCPCS coding, clinical documentation standards, and medical terminology.
• Experience with EMRs, healthcare databases, and reporting tools.
• Strong leadership, analytical, organizational, and project management skills.
• Excellent communication and stakeholder management abilities.
• Proficiency in Microsoft Office Suite, including Excel and PowerPoint.

Preferred Qualifications

• Experience in Managed Care, Medicaid, Medicare Advantage, or Health Insurance.
• Experience leading HEDIS operations, data validation, quality reporting, or audit activities.
• CPHQ, RHIA, RHIT, CPC, CCS, PMP, or similar professional certification preferred.

Compliance & Regulatory Responsibilities

Noted above.

Hiring Range

Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430
All Other Locations (within approved locations): $88,700 - $131,920