Manager, Clinical Quality & Analytics

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Job Summary

The Manager, Clinical Quality & Analytics is a high-impact, hands-on leadership role designed for a "systems thinker" who bridges the gap between clinical expertise and data science. You will not only oversee Clinical Quality Control (QC) operations but will actively build the analytical frameworks, dashboards, and AI-logic refinements that drive financial impact for our payer customers. We are looking for a builder—someone who can lead a team of clinical Subject Matter Experts (SMEs) while personally diving into SQL, data trends, and AI engine improvements.

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Key Responsibilities

1. Clinical Quality Leadership & Strategy

• Lead and mentor a team of clinical SMEs responsible for ICD-10 coding accuracy, HEDIS abstraction, Risk Adjustment (HCC/RAF), and Clinical Documentation Integrity (CDI).

• Transform QC from a purely clinical function into a structured, data-driven operation.

• Implement "quality gates," error tracking, and root-cause analysis to ensure continuous improvement in coding accuracy.

2. AI Engine Optimization & Technical Contribution

• Actively partner with Product and Engineering teams to improve our AI-driven coding engine.

• Develop and refine query logic and phrase-matching to enhance the engine's precision.

• Create a "closed-loop" system where QC insights are translated into structured technical improvements for AI performance.

3. Healthcare Data Analytics & Financial Impact

• Serve as the internal authority on how clinical data translates to financial outcomes (RAF score movement and quality gap closure).

• Analyze complex trends across diverse populations to explain the "why" behind data shifts.

• Utilize advanced Excel and SQL (and ideally Python) to generate actionable insights that standard reports may miss.

4. Dashboard Development & Executive Storytelling

• Design and build an analytics layer/executive dashboard for payer customers.

• Define and visualize key metrics including coding accuracy trends, revenue impact, and STARS performance.

• Translate complex data sets into clear, compelling narratives for executive-level client presentations.

5. Strategic Problem Solving

• Serve as an elite analytical resource for ambiguous, ad-hoc problems for both internal teams and external clients.

• Support high-level customer needs that require deeper technical or data-driven rigor than typical SME capabilities.

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Qualifications

• Core Credentials: RHIA, CRC, CCS, CCDS, or similar professional coding/clinical certification is required.

• Experience: * 7+ years in healthcare, starting in a clinical role (Coder, CDI Specialist, or Clinical Quality) and evolving into Data Analytics.

  • Proven track record in a leadership or management capacity.

• Technical Mastery:

  • Advanced Excel: Expert-level proficiency (Pivot tables, complex formulas, data modeling).

  • Data Viz: Experience building or contributing to dashboards in Tableau or Power BI.

  • SQL: Strong proficiency is preferred to query and explore data independently.

  • Programming: Exposure to Python or data engineering is a significant plus.

• Domain Expertise:

  • Deep knowledge of ICD-10-CM, HEDIS/NCQA measures, and Risk Adjustment (HCC/RAF).

  • Strong understanding of Clinical Documentation Integrity (CDI) practices.

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Key Traits for Success

• Creative Problem Solver: Ability to "build from scratch" and improve existing systems.

• Hands-on Leader: A willingness to "do the work" alongside the team rather than just delegating.

• Systems Thinker: Ability to see patterns, identify root causes, and build scalable solutions.

• Client-Facing Presence: Professional, collaborative, and capable of translating technical complexity into value for customers.

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What Success Looks Like

1. Measurable Accuracy: A quantifiable lift in coding and HEDIS accuracy.

2. Operational Rigor: A structured QC function that relies on data rather than intuition.

3. AI Synergy: A measurable improvement in AI coding performance driven by QC feedback.

4. Market Differentiation: An analytics platform that becomes a primary selling point for the organization.

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