Your Role

The Clinical Quality Analytics and Informatics 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 - Senior will report to the Clinical Quality Manager or Senior Manager. 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 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:

• Conduct independent analysis of high complexity under moderate supervision and guidance, develop novel analyses and reports
• Develop documentation and create and execute workplans for analyses of high complexity
• Produce analysis of high complexity under the guidance and direction of Clinical Quality Analyst - Consultant or Principal or Manager
• Design, build, and enhance data systems and applications so that they better serve specific reporting requirements
• Identify business risks relating to report design and production
• Collect data from various internal systems (example Claims processing or membership systems) and external systems (EMR/EHR) and converts those data to actionable insights to guide business decision making for BSC populations' health management and quality of care
• Produce monthly provider and/or employer group specific reports based on HEDIS measures in alignment with reporting quality ratings systems such as NCQA Stars/Accreditation, Medicare Stars, Medi-Cal Managed Care Accountability Sets, Quality Transformation Initiative and Quality Rating System
• Partner with the HEDIS data team, Clinical Quality Analytics and Medical Record Review teams to support HEDIS performance improvement initiatives

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 2 years of SAS/SQL programming experience
• Requires at least 5 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
• Requires at least 2 years of programming using inpatient claims, outpatient encounters, membership, pharmacy or laboratory data.
• Requires at least 2 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 3 years of experience in Health Care (managed care, academic, or gov't payer)
• Requires at least 1 year of experience working with NCQA HEDIS quality measures
• Requires at least 1 year of experience with NCQA Health Plan Rating, CMS Medicare Advantage Star Rating or Medi-Cal Managed Care Accountability Sets (MCAS)

Pay Range:

The pay range for this role is: $ 99000.00 to $ 148500.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.