Senior HEDIS Data Consultant in Washington, District of Columbia at Educology Solutions

JOB SUMMARY

The Senior HEDIS Data and Measurement Technical Consultant will provide specialized technical expertise supporting the organization’s HEDIS data, measurement platforms, integrations, and reporting processes. This contractor will focus on the technical challenges associated with acquiring, transforming, validating, processing, and reconciling data used for HEDIS measure calculation and submission.
The consultant will work closely with IT, Data Engineering, Quality, Analytics, vendors, and source-system teams to identify and resolve technical issues that affect measure accuracy, completeness, timeliness, and audit readiness. This role does not own clinical quality strategy, measure performance improvement initiatives, or business interpretation of HEDIS requirements.

DUTIES & RESPONSIBILITIES

HEDIS Data and Integration
Analyze data from claims, encounters, enrollment, pharmacy, laboratory, provider, clinical, supplemental, and medical-record sources.
Define and validate source-to-target mappings for HEDIS data feeds.
Identify data gaps, duplicate records, missing values, coding discrepancies, and inconsistencies across source systems.
Support the development and maintenance of ETL processes, data pipelines, file exchanges, APIs, and vendor interfaces.
Establish and document data-source precedence and reconciliation rules in collaboration with HEDIS business owners.
Troubleshoot failed, incomplete, delayed, or inaccurate data loads.
Validate member eligibility, continuous enrollment, benefit coverage, provider attribution, event dates, and clinical data elements used in measure processing.

HEDIS Measurement Systems
Provide technical support for HEDIS measurement platforms, data repositories, abstraction tools, and reporting solutions.
Analyze measure-calculation output and trace results back to source data and transformation logic.
Investigate unexpected numerator, denominator, exclusion, compliance, and eligible-population results.
Support measure configuration, system upgrades, annual HEDIS specification changes, and regression testing.
Assist with implementation or replacement of HEDIS engines and related data platforms.
Coordinate technical activities with HEDIS vendors, including Cotiviti, Arcadia, Inovalon, or similar organizations.
Validate vendor-generated measure results against internal data and expected outcomes.

Data Quality and Validation
Develop repeatable data-quality controls, balancing processes, exception reports, and reconciliation procedures.
Perform record-level and aggregate validation of data submitted to HEDIS platforms.
Compare measure results across environments, systems, vendors, and reporting periods.
Support root-cause analysis and corrective action for measure discrepancies.
Document technical issues, business impact, resolution, and preventive controls.
Support validation of supplemental data sources and electronic clinical data used for HEDIS reporting.

Testing and Implementation
Develop technical test plans, test cases, expected results, and traceability documentation.
Support unit, system integration, regression, parallel, performance, and production-validation testing.
Validate annual measure updates and changes to data mappings, transformations, and system configurations.
Coordinate defect triage and resolution with internal teams and external vendors.
Support production-readiness reviews and post-implementation validation.

Audit and Submission Support
Provide technical support for HEDIS audits, roadmap reviews, source-system validation, and auditor inquiries.
Produce data lineage, mapping, transformation, control, and system-process documentation.
Support the preparation and validation of data used for IDSS and other required HEDIS submissions.
Assist in resolving technical findings identified during audit or submission activities.
Maintain evidence demonstrating the completeness, accuracy, and control of HEDIS data processes.

Knowledge Transfer and Documentation
Document the current HEDIS technical architecture, data flows, integrations, dependencies, and operational processes.
Develop technical runbooks, data dictionaries, mapping documents, issue logs, and troubleshooting guides.
Shadow existing HEDIS technical resources and capture institutional knowledge.
Provide structured knowledge transfer to employees and other contractors.
Recommend improvements to data architecture, automation, monitoring, testing, and operational controls.

QUALIFICATIONS

Seven or more years of experience in healthcare data, payer technology, healthcare analytics, or data engineering.
At least three years of direct technical experience supporting HEDIS measurement or quality-reporting platforms.
Strong knowledge of HEDIS data structures, measure processing, eligible populations, numerators, denominators, exclusions, and supplemental data.
Experience working with claims, encounters, enrollment, provider, pharmacy, laboratory, clinical, and medical-record data.
Demonstrated experience troubleshooting HEDIS measure discrepancies at the member and data-element level.
Experience with SQL, relational databases, data profiling, ETL processes, and large healthcare datasets.
Experience supporting HEDIS platform implementations, migrations, upgrades, or annual specification changes.
Strong understanding of data lineage, source-to-target mapping, reconciliation, data-quality controls, and test validation.
Experience working with HEDIS vendors and cross-functional payer teams.
Strong technical documentation, problem-solving, and communication skills.

Preferred Qualifications
Experience with Cotiviti, Arcadia, Inovalon QSI-XL, or comparable HEDIS platforms.
Experience replacing or migrating a HEDIS measurement engine.
Familiarity with QNXT or other health-plan claims administration platforms.
Familiarity with FHIR, USCDI, clinical data exchange, ECDS measures, and electronic clinical data sources.
Experience supporting NCQA audits and IDSS submissions.
Knowledge of standard healthcare code sets, including ICD-10, CPT, HCPCS, NDC, LOINC, SNOMEDCT, and RxNorm.
Experience with cloud data platforms, data lakes, Azure, Databricks, Snowflake, or similar technologies.
Experience supporting Medicare, Medicaid, commercial, and Marketplace health-plan populations.

Expected Deliverables
Current-state HEDIS technical architecture and data-flow documentation.
Inventory of HEDIS data sources, interfaces, mappings, and dependencies.
Technical gap and risk assessment.
Data-quality and reconciliation framework.
Documented measure-discrepancy investigation process.
Technical test strategy and reusable test cases.
Issue, defect, and remediation tracking.
HEDIS engine migration or implementation support, when applicable.
Knowledge-transfer plan, training materials, and operational runbooks.
Recommendations for improving automation, scalability, monitoring, and data accuracy.
Measures of Success
The consultant’s performance will be evaluated based on:
Timely identification and resolution of HEDIS data and measure-processing issues.
Reduction in unexplained measure-result discrepancies.
Improved completeness, accuracy, and traceability of HEDIS data.
Successful completion of system testing, annual measure updates, and production validation.
Readiness for HEDIS audits and submissions.
Quality and completeness of technical documentation and knowledge transfer.
Effective coordination with internal teams and external vendors.