Job Summary

The Senior Manager, who will also function as a HEDIS Project Lead, is the accountable business and clinical owner of the HEDIS and Core Measure program across all product lines. This role is responsible for clinical interpretation of measures, reporting strategy, audit readiness, and cross-functional coordination to ensure HEDIS and Core Measure results are accurate, compliant, and defensible.

This role serves as the primary authority for what is reported and why, partnering closely with the HEDIS/Core Measure Technical Lead, MRR leadership, and business stakeholders. The role operates on a year-round cadence, supporting design, validation, production, audit, and submission activities.


Essential Functions:
 

• • HEDIS Program & Clinical Leadership
  • Owns overall HEDIS and CMS Core Measures clinical strategy and reporting intent across product lines
  • Interprets NCQA HEDIS specifications, CMS Core Measures specifications, FAQs, and technical guidance
  • Determines measure inclusion/exclusion, hybrid vs. administrative approach, and reporting decisions
  • Provides clinical judgment and escalation support for complex or ambiguous scenarios
  • Monitors NCQA HEDIS updates, CMS Core Measures updates, technical bulletins, FAQs, and measure changes
  • Assess the impact of upcoming HEDIS and CMS Core Measure changes on organization programs, data sources, and workflows
  • Partners with IS (Information Systems) to identify and ensure changes are made outside of production season:
  ◦ New or modified measures
  ◦ Required data sources or automations
  ◦ Requirements or simplifications of existing logic
  (25%)

• Medical Record Review (MRR) Oversight
  • Partners with the MRR Manager on MRR strategy, reconciliation, and quality oversight
  (10%)

• QA / UAT (Clinical)
  • Owns clinical QA/UAT for:
  ◦ New or modified measures
  ◦ HEDIS and Core Measures main software (Cotiviti) data and refreshes plus other Supplemental Data Sources (SDS)
  ◦ CAHPS samples and outputs
  • Confirms outputs align with clinical intent prior to audit and submission
  (25%)

• Audit & Roadmap Ownership
  • Owns business and clinical content of the HEDIS and CMS Core Measures Roadmap
  • Leads clinical responses to audit questions and issue logs
  • Serves as a primary clinical point of contact for external auditors
  (25%)

• Cross-Functional Leadership
  • Works closely with IS, Product Line Managers (PLMs), Population Health/QI, MRR, and vendors
  • Ensure business stakeholders are engaged early and consistently
  • Supports governance and decision-making across the HEDIS and CMS Core Measure lifecycle
  (15%)

Education:
 

• Bachelor's degree in healthcare, public health, nursing, health administration, or related field required

Work Experience:
 

• 4-6 years of experience in HEDIS, quality measurement, NCQA, or healthcare quality analytics required AND

• 1-3 years clinical background (RN) or equivalent clinical informatics experience required AND

• 3-5 years previous management experience required

Licenses:

Knowledge, Skills and Abilities:
 

• Demonstrated experience interpreting HEDIS measures and NCQA requirements

• Experience supporting or participating in HEDIS audits

• Strong written and verbal communication skills, including audit-facing communication

• Preferred Qualifications
  
  • 7+ years of progressive HEDIS or quality program leadership experience
  
  • Demonstrated experience interpreting CMS Core Measures and CMS reporting requirements
  
  • Experience serving as a primary clinical lead or decision-maker during an audit
  
  • Familiarity with HEDIS vendor platforms (e.g., Cotiviti)
  
  • Experience supporting CAHPS processes and submissions