Clinical Quality Analytics, Consultant

Your Role

The Clinical Quality Analytics team delivers best-in-class clinical quality analytics and informatics to enable high quality and affordable member-centered care. Our data, intelligence, and actionable insights help drive quality strategy, performance improvement, and regulatory reporting.  The Clinical Quality Analyst - Consultant will report to the Clinical Quality Analytic Senior Manager under the day-to-day supervision of the Clinical Quality Analytics – Principal, Medicare Lead. In this role you will provide data, analytic and reporting support for the Clinical Quality Department to improve Blue Shield of California and Promise Health Plan - Medicare quality performance for regulatory and accreditation requirements including National Committee for Quality Assurance, Centers for Medicare and Medicaid and Department Health Care Service.

Your Work

In this role, you will:

• Partner with the Clinical Quality Medicare Quality Improvement, Clinical Quality Analytics and Medical Record Review teams to support HEDIS performance improvement initiatives
• Conduct independent analysis of high complexity under minimal supervision and guidance
• Collect data from various internal systems (example Claims processing or membership systems) and external systems (EMR/EHR) and convert those data to actionable insights to guide business decision making for BSC populations' health management and quality of care
• Develop, implement, and document quality assurance (QA) processes to ensure that reported data is accurate and reliable
• Conduct program evaluation, vendor assessments, performance guarantees using advanced statistical modeling
• Produce analysis of high complexity under the guidance and direction of Clinical Quality Analyst – Principal
• Develop documentation and create and execute workplans for analyses of high complexity. Workplans may coordinate the activities of Clinical Quality Analysts at lower levels and may involve collaboration with more than one team
• Provide training and mentoring for team members on best practices for analysis and reporting; assist in the development of supplemental analytic training tools and materials 

Your Knowledge and Experience

• Requires a bachelor’s degree in health science, quantitative social science, public health, health services research or business or equivalent experience
• Prefer an MPH, MBA, MS, MA, RN, or RHIA in health science, quantitative social science, public health, health services research or business
• Requires at least 5 years of SAS/SQL programming experience
• Requires at least 7 years of prior operational and / or data analysis experience, experience in database structures, and standard query and reporting tools
• Proficient in MS Office – Word, Excel and Powerpoint
• Experience with visual management tools (eg. Tableau, Power BI) or task management tools (eg. JIRA, Work Front, Sharepoint) or cloud data (eg. Azure, AWS, Snowflake)

• Experience working with RDBMS: Oracle, Netezza, DB2 etc. 

• Requires at least 5 years of programming using inpatient claims, outpatient encounters, membership, pharmacy or laboratory data. 

• Requires at least 5 years of experience with ICD (International Classification of Diseases) codes, CPT (Current Procedural Terminology) codes, Diagnostic Related Group (APR-DRG/MS-DRG) codes or Healthcare Common Procedure Coding System (HCPCS) codes

• Requires at least 5 years of experience in Health Care (managed care, academic, or gov't payer)

• Requires at least 3 years of experience working with NCQA HEDIS quality measures

• Experience utilizing certified HEDIS software

• Requires at least 3 years of experience with NCQA Health Plan Rating, CMS Medicare Advantage Star Rating or Medi-Cal Managed Care Accountability Sets (MCAS)