Manager Clinical Quality Data Validation and Governance

About this role

The Manager, Clinical Quality Data Validation & Governance provides strategic and operational leadership for HEDIS clinical data validation, supplemental data governance, and quality reporting activities. This role is responsible for ensuring the accuracy, integrity, compliance, and audit readiness of clinical data used for NCQA, CMS, state, and organizational reporting requirements. The Manager leads a team of Clinical Quality Specialists and partners with Clinical IT, Enterprise Delivery Services, DSE, and Operations teams to drive regulatory performance, data quality, and continuous improvement initiatives.

This position follows a hybrid work model consisting of remote and office-based work. Office location: 100 Church Street, New York, NY.

Essential Duties and Responsibilities:

Strategy, Governance & Compliance • Leads governance and oversight of HEDIS clinical supplemental data sources, clinical data validation, medical record review, and supplemental data processes. • Establishes and maintains data quality standards, validation controls, and audit readiness processes. • Ensures compliance with NCQA, CMS, state, and organizational requirements. • Identifies and mitigate data quality, compliance, and reporting risks. • Supports HEDIS audits, supplemental data reviews, and regulatory reporting activities.

Operations & Performance Management • Oversees clinical data validation, abstraction, and quality assurance activities. • Monitors productivity, accuracy, quality metrics, and reporting deadlines. • Investigates and resolves data discrepancies, documentation gaps, and operational issues. • Develops and maintains operational reports, dashboards, and performance metrics. • Manages relationships with vendors, provider organizations, and delegated entities.

Team Leadership • Supervises, coaches, and develops Clinical Quality Specialists and related staff. • Manages hiring, onboarding, performance evaluations, and workforce planning activities. • Establishes productivity, quality, and performance expectations. • Fosters a culture of accountability, collaboration, and continuous improvement.

Collaboration • Partners with Clinical IT, Enterprise Delivery Services, DSE, and Operations teams to support organizational quality goals. • Communicates performance results, audit outcomes, and strategic recommendations to leadership and stakeholders. • Performs additional duties as necessary and as directed.

Minimum Qualifications:

Education • Bachelor's degree in Nursing, Public Health, Health Administration, Healthcare Management, Health Informatics, or a related field required from an accredited institution.

Experience • Five (5) years of experience in healthcare quality, HEDIS operations, clinical data validation, healthcare analytics, or quality improvement. • Two (2) years of supervisory or leadership experience.

Knowledge, Skills, and Abilities • Strong knowledge of NCQA HEDIS, supplemental data standards, STAR, QARR, and regulatory reporting requirements. • Knowledge of ICD-10, CPT, HCPCS coding, clinical documentation standards, and medical terminology. • Experience with EMRs, healthcare databases, and reporting tools. • Strong leadership, analytical, organizational, and project management skills. • Excellent communication and stakeholder management abilities. • Proficiency in Microsoft Office Suite, including Excel and PowerPoint.

Preferred Qualifications: • Experience in Managed Care, Medicaid, Medicare Advantage, or Health Insurance. • Experience leading HEDIS operations, data validation, quality reporting, or audit activities. • CPHQ, RHIA, RHIT, CPC, CCS, PMP, or similar professional certification preferred.

Compliance & Regulatory Responsibilities: Noted above. License/Certification: N/A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.  HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org  or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services,  LLC.

Know Your Rights

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst.  Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*: • Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430

• All Other Locations

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