Senior Auditor, Healthcare

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $100k - $130k / year

⏰ Full Time

🟠 Senior

🔎 Auditor

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Health Services Advisory Group, Inc. (HSAG)

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1979

🏥 Healthcare

⚕️ Healthcare Insurance

🏛️ Government

Healthcare • Healthcare Insurance • Government

Health Services Advisory Group, Inc. (HSAG) is a mission-driven healthcare quality improvement organization that partners with federal and state agencies, health plans, and providers to improve care delivery and patient outcomes. HSAG provides data science and advanced analytics, survey administration, medical record case review, audits, and healthcare consulting services to support Medicare and Medicaid quality programs, waiver evaluations, kidney health initiatives, and national patient surveys. The organization focuses on regulatory compliance, performance measurement, and evidence-based quality improvement to drive better outcomes across the healthcare continuum.

📋 Description

• Conduct complex healthcare performance measure validation (PMV) activities • Apply HEDIS Compliance Audit principles and techniques to HEDIS and non-HEDIS performance measures in accordance with technical specifications, contractual requirements, and CMS EQR Protocol 2 • Evaluate information systems, data integrity, measure calculation processes, source code, programming logic, medical record review processes, and reported performance measure results • Lead and conduct HEDIS compliance audits and performance measure validation activities • Conduct information systems assessments and evaluate systems and processes supporting performance measure calculation and reporting • Assess enrollment, claims/encounter, provider, pharmacy, laboratory, medical record, supplemental, vendor, and other data sources • Review source code, programming logic, data mapping, measure workflows, and calculation methodologies • Validate denominator, numerator, exclusions, eligibility, continuous enrollment, clinical coding, sampling, and measure-specific requirements • Conduct primary source verification and record-level testing • Evaluate medical record review processes, abstraction methodologies, sampling, and quality-control procedures • Lead virtual and onsite audit activities and interview client staff • Identify audit findings, assess impact on measure validity, and develop evidence-based conclusions and recommendations • Prepare and review audit workpapers, validation tools, findings, and client-facing reports • Provide senior-level review, technical guidance, and mentoring to auditors and project staff • Communicate technical findings to clients, state Medicaid agencies, internal leadership, and stakeholders • Support continuous improvement of audit methodologies, tools, workpapers, and reporting processes • Maintain current knowledge of HEDIS requirements, CMS EQR protocols, CMS Core Set specifications, and performance measurement standards

🎯 Requirements

• 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: experience conducting NCQA HEDIS Compliance Audits; performance measure validation under CMS EQR Protocol 2; Medicaid and/or CHIP managed care programs; CMS Core Set, state-defined, or other non-HEDIS performance measures; information systems assessments, primary source verification, medical record review validation, and source code review; SQL, SAS, Python, or similar data-query or programming tools • Advanced knowledge of HEDIS performance measurement and audit concepts • Knowledge of CMS EQR performance measure validation requirements and methodologies • 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