SME (Subject Matter Expert) - Clarus RCM India Private Limited
(2025-11)
- Act as a Subject Matter Expert (SME) for HEDIS measures, providing guidance on NCQA HEDIS technical specifications, measure logic, and data validation requirements.
- Gather, analyze, and document business requirements from healthcare stakeholders and translate them into functional requirements, BRD, and FRD documents.
- Work closely with data teams, developers, and QA teams to implement HEDIS measure logic and ensure accurate data processing.
- Analyze healthcare data, claims data, and medical record data to identify gaps impacting HEDIS performance and quality scores.
- Provide functional expertise during HEDIS abstraction, Primary Source Verification (PSV), and Over-Read (OR) validation processes.
- Develop process workflows, data flow diagrams, and business process documentation to improve HEDIS reporting operations.
- Participate in HEDIS audits, compliance reviews, and quality assurance processes to ensure data accuracy and regulatory compliance.
- Support development of HEDIS dashboards, reports, and performance metrics for leadership and quality improvement initiatives.
- Provide training and knowledge support to HEDIS abstractors and analysts regarding measure logic and abstraction guidelines.
Hedis Analyst - Optum Health and Technology India Private Limited
(2023-02 - 2025-11)
- Perform medical record abstraction and chart review to collect clinical data for HEDIS quality measures according to NCQA guidelines.
- Review patient medical records, EMR/EHR systems, and clinical documentation to identify required data elements for HEDIS reporting.
- Abstract and validate HEDIS measures such as CBP (Controlling High Blood Pressure), CDC (Comprehensive Diabetes Care), BCS (Breast Cancer Screening), COL (Colorectal Cancer Screening), TRC (Transition of Care), COA (Care of Older Adults), KED (Kidney Health Evaluation), OMW (Osteoporosis Management Women), SPD (Statin Therapy for Patient Diabetes), SPC (Statin Therapy for Cardiovascular Patient), FMC (High Risk Multiple Chronic Condition).
- Ensure accuracy and completeness of HEDIS data collection and abstraction based on NCQA technical specifications.
- Perform Primary Source Verification (PSV) and support Over-Read (OR) audits to maintain quality and data accuracy.
- Identify documentation gaps and discrepancies in medical records and escalate issues to quality teams or supervisors.
- Work with healthcare tools such as DataRAP, EPRG, Citrix, Athena tool (AWS) and eClinicalWorks for chart abstraction and data entry.
- Maintain high levels of abstraction accuracy, productivity, and quality benchmarks as defined by project or client requirements.
- Ensure compliance with NCQA, CMS, and HIPAA regulations while handling patient health information.
Senior Process Executive - Episource India Private Limited
(2020-06 - 2023-02)
- Perform medical record abstraction and chart review to collect clinical data for HEDIS quality measures according to NCQA guidelines.
- Review patient medical records, EMR/EHR systems, and clinical documentation to identify required data elements for HEDIS reporting.
- Abstract and validate HEDIS measures such as CBP (Controlling High Blood Pressure), CDC (Comprehensive Diabetes Care), BCS (Breast Cancer Screening), COL (Colorectal Cancer Screening), TRC (Transition of Care), COA (Care of Older Adults), KED (Kidney Health Evaluation), OMW (Osteoporosis Management Women), SPD (Statin Therapy for Patient Diabetes), SPC (Statin Therapy for Cardiovascular Patient), FMC (High Risk Multiple Chronic Condition).
- Ensure accuracy and completeness of HEDIS data collection and abstraction based on NCQA technical specifications.
- Perform Primary Source Verification (PSV) and support Over-Read (OR) audits to maintain quality and data accuracy.
- Identify documentation gaps and discrepancies in medical records and escalate issues to quality teams or supervisors.
- Work with healthcare tools such as DataRAP, EPRG, Citrix, and eClinicalWorks for chart abstraction and data entry.
- Maintain high levels of abstraction accuracy, productivity, and quality benchmarks as defined by project or client requirements.
Process Executive - Buzzworks Business Private Limited
(2018-09 - 2020-05)
- HEDIS - Patient Chart Analyzer.
- Perform medical record abstraction and chart review to collect clinical data for HEDIS quality measures according to NCQA guidelines.
- Perform Primary Source Verification (PSV) and support Over-Read (OR) audits to maintain quality and data accuracy.
