Manager Clinical Quality Data Validation and Governance

Description and Requirements

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.

• 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.

• 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.

• 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.

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

• 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.

• 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.

• 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.