Note: The job is a remote job and is open to candidates in USA. Healthcare IS is seeking a HEDIS Data Analyst / Business Analyst with extensive experience in healthcare payer environments. The role involves analyzing healthcare data to support HEDIS and CMS initiatives, ensuring accurate reporting, and collaborating with various teams to drive quality improvement.
Responsibilities
- Support HEDIS measurement, reporting, validation, and annual submission activities
- Interpret HEDIS measure specifications and translate business requirements into data and reporting solutions
- Analyze HEDIS performance results and identify opportunities to improve quality scores and close care gaps
- Partner with quality, population health, provider engagement, and care management teams to support HEDIS initiatives
- Assist with HEDIS audits, documentation reviews, and quality assurance activities
- Gather, analyze, document, and validate business requirements from health plan stakeholders. Perform root cause analysis on data quality issues impacting HEDIS, CMS reporting, and operational performance
- Develop source-to-target mappings, business rules, process flows, and functional specifications
- Analyze large healthcare datasets and present findings, trends, and recommendations to business stakeholders
- Support UAT testing, reconciliation, defect resolution, and deployment validation activities. Analyze claims, encounters, eligibility, provider, pharmacy, and supplemental data used for HEDIS and CMS reporting
- Validate data completeness, accuracy, reconciliation results, and reporting outputs
- Support CMS quality initiatives, STAR Ratings programs, and regulatory reporting requirements
- Collaborate with business and technical teams to improve reporting processes and data governance practices
- Understand payer operational workflows including claims processing, provider data, membership, enrollment, and quality management programs
- Work directly with consultants and client stakeholders to solve complex payer data challenges
- Facilitate requirements sessions, stakeholder interviews, and process reviews
- Translate technical findings into business recommendations and executive-level communications
- Support delivery of strategic payer transformation and data modernization initiatives
Skills
- Bachelor's degree in Healthcare Administration, Information Systems, Business, Data Analytics, Public Health, or related field
- Additional relevant work experience in lieu of degree may be considered
- 4–6+ years of healthcare payer, health plan, or managed care experience
- Strong hands-on HEDIS knowledge and experience supporting HEDIS reporting initiatives
- Experience working within a Health Plan, Managed Care Organization, Medicare Advantage, Medicaid, or Commercial payer environment
- Understanding of CMS regulations, CMS STAR Ratings, quality programs, and regulatory reporting requirements
- Experience analyzing healthcare data including Claims Encounters, Membership/Eligibility Provider Data, Pharmacy Data, Supplemental Clinical Data
- Strong business analysis skills including requirements gathering, process documentation, and stakeholder management
- Advanced SQL experience for healthcare data analysis and validation
- Experience performing data quality reviews, reconciliations, and root cause analysis
- Strong communication and presentation skills
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