Quality Analyst (Remote)

CareFirst•Baltimore, MD

2d•Remote

About The Position

The Quality Analyst supports HEDIS, Stars, regulatory, quality improvement, and population health initiatives across lines of business by retrieving and reviewing medical records, analyzing quality data, supporting audit readiness, and operationalizing initiatives that improve care quality, member experience, gap closure, and population-level outcomes. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

Requirements

Bachelor's Degree in population health, public health, healthcare administration, business administration, health policy, economics, statistics, mathematics, data science, or a related field; OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
3 years professional experience in a business environment (public health, health insurance, management consulting fields preferred); evidence of progressing levels of work experience.
Expertise in qualitative and quantitative data analyses and presentations.
Ability to conduct advanced analytics using SQL, Python, R, or similar.
Fluent in the use of Microsoft tools including Excel, Word, Power Point and Outlook.
Knowledge of healthcare claims, survey, clinical, and health data.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Eligible to work in the U.S. without Sponsorship.

Nice To Haves

RN-BC - Certified General Nursing Practice.
Certification in Quality or Process Improvement Methods preferred.
Direct experience with HEDIS, NCQA accreditation, CAHPS, CMS quality programs, Stars, quality improvement, regulatory reporting, or related quality activities in a healthcare, managed care, payer, provider, or HEDIS vendor environment.
Data analytics experience working with healthcare data, large data sets, dashboards, trackers, or reports to answer clinical, operational, quality, or business questions.
Experience with medical record retrieval, provider outreach, medical record abstraction, overread or quality review, pend research, supplemental data, primary source verification, and audit readiness workflows.
Experience applying HEDIS measure specifications and medical record review guidelines to support accurate gap closure, reporting, supplemental data use, and quality performance improvement.
Experience using Microsoft Office tools and web-based applications; familiarity with HEDIS or medical record review platforms such as Cotiviti, Inovalon, Reveleer, or similar systems preferred.
At least two consecutive HEDIS seasons with the same company preferred.

Responsibilities

Coordinate medical record retrieval, provider outreach, intake, upload, routing, follow-up, and documentation activities for HEDIS, Stars, quality performance, regulatory reporting, Risk Adjustment support, and assigned Quality initiatives.
Validate provider/facility information, document outreach efforts, escalate barriers, and ensure records are received from the appropriate provider group and assigned to the correct project.
Perform medical record abstraction, research, and quality review by applying current HEDIS and NCQA measure specifications, company training guidelines, and project requirements.
Accurately document findings, create and resolve routine pends, support discrepancy resolution, and maintain productivity, turnaround, accuracy, and quality expectations.
Support audit readiness and data integrity activities, including primary source verification for supplemental data, record and invoice review related to medical record retrieval projects, validation of receipt and project assignment, reconciliation of missing or incomplete documentation, and maintenance of compliant documentation for internal and external review.
Analyze workflow, quality, productivity, and measurement trends to identify improvement opportunities, support targeted retrieval and gap-closure strategies, prepare actionable reports or summaries, and collaborate with internal teams, vendors, and provider-facing partners to improve HEDIS and quality outcomes across lines of business.
Maintain subject matter knowledge of HEDIS, NCQA, CMS quality standards, accreditation expectations, medical record review processes, HIPAA requirements, and quality operations.
Support development and maintenance of training materials, standard operating procedures, job aids, workflow documentation, and cross-training resources; perform other duties as assigned.