Senior Auditor (Healthcare)

Summary

The Senior Auditor conducts complex healthcare performance measure validation (PMV) activities. This position applies Healthcare Effectiveness Data and Information Set® (HEDIS) Compliance Audit principles, techniques, and professional judgment to the validation of HEDIS and non-HEDIS performance measures in accordance with applicable technical specifications, contractual requirements, and the Centers for Medicare/Medicaid Services (CMS) External Quality Review (EQR) Protocol 2. The Senior Auditor evaluates information systems, data integrity, measure calculation processes, source code and programming logic, medical record review processes, and reported performance measure results to determine whether measures are accurate, reliable, and calculated in accordance with established specifications. The Senior Auditor will have the ability to work independently while providing technical leadership and mentoring to other staff.

Essential Competencies, Duties and Responsibilities

• Lead and conduct HEDIS compliance audit and performance measure validation activities.
• Apply HEDIS audit techniques and methodologies to HEDIS, CMS Core Set, state-defined, HRSA, AHRQ, and other performance measures, as applicable.
• Conduct information systems assessments and evaluate systems and processes supporting performance measure calculation and reporting.
• Assess the accuracy, completeness, and integration of enrollment, claims/encounter, provider, pharmacy, laboratory, medical record, supplemental, vendor, and other applicable data sources.
• Review source code, programming logic, data mapping, measure workflows, and calculation methodologies for compliance with measure specifications.
• Validate denominator, numerator, exclusions, eligibility, continuous enrollment, clinical coding, sampling, and other measure-specific requirements.
• Conduct primary source verification and record-level testing to verify the accuracy of source data and reported results.
• Evaluate medical record review processes, abstraction methodologies, sampling, and quality-control procedures, as applicable.
• Lead virtual and onsite audit activities and conduct interviews with client staff responsible for information systems, data management, programming, quality measurement, and reporting.
• Identify audit findings, assess their impact on measure validity, and develop clear, evidence-based conclusions and recommendations.
• Prepare and review audit workpapers, validation tools, findings, and client-facing reports.
• Provide senior-level review and technical guidance to auditors and other project staff.
• Communicate complex technical findings effectively to clients, state Medicaid agencies, internal leadership, and other stakeholders.
• Support development and continuous improvement of audit methodologies, tools, workpapers, and reporting processes.
• Maintain current knowledge of HEDIS requirements, CMS EQR protocols, CMS Core Set specifications, and other applicable performance measurement standards.

Minimum Qualifications

• Bachelor's degree in healthcare administration, public health, health information management, nursing, information systems, statistics, data analytics, or a related field.
• Significant experience in HEDIS compliance auditing, healthcare performance measurement, performance measure validation, healthcare data validation, or a related field.
• Demonstrated ability to interpret and apply complex performance measure specifications.
• Experience evaluating healthcare information systems, data flows, and data used for performance measure reporting.
• Experience reviewing source code, programming logic, or measure calculation methodologies, directly or in collaboration with technical staff.
• Experience conducting audits, developing findings, documenting supporting evidence, and communicating results to clients and stakeholders.
• Demonstrated ability to lead complex audit activities and provide technical guidance to other staff.

Preferred Qualifications

• Experience conducting NCQA HEDIS Compliance Audits.
• Experience conducting performance measure validation under CMS EQR Protocol 2.
• Experience with Medicaid and/or CHIP managed care programs.
• Experience validating CMS Core Set, state-defined, or other non-HEDIS performance measures.
• Experience with information systems assessments, primary source verification, medical record review validation, and source code review.
• Familiarity with SQL, SAS, Python, or similar data-query or programming tools.

Knowledge, Skills, and Abilities

• Advanced knowledge of HEDIS performance measurement and audit concepts.
• Knowledge of CMS EQR performance measure validation requirements and methodologies.
• Ability to apply established HEDIS audit techniques to HEDIS and non-HEDIS performance measures.
• Strong understanding of healthcare information systems, data flows, and performance measure calculation processes.
• Strong analytical, investigative, and problem-solving skills.
• Ability to interpret technical specifications and translate them into effective audit procedures.
• Sound professional judgment in evaluating audit evidence and determining the significance of findings.
• Strong written, verbal, and interpersonal communication skills.
• Ability to prepare clear, concise, and defensible technical documentation.
• Ability to manage multiple priorities and meet contractual and regulatory deadlines.
• Ability to work independently while providing technical leadership and mentoring to other staff.