Job DescriptionYour RoleThe 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 - Consultant 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.
ResponsibilitiesYour WorkIn this role, you will:
- Conduct independent analysis of high complexity under minimal supervision and guidance.
- Develop analytical methods so that they may be subsequently delegated for production to Clinical Quality Analysts at lower levels.
- Produce analysis of high complexity under the guidance and direction of Clinical Quality Analyst - Principal or manager.
- Develop documentation and create and execute workplans for analyses of high complexity. Workplans may coordinate the activities of Medical Informatics 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; conducts formal training sessions for lower level analysts and analysts in other Departments Conduct independent analysis of high complexity under moderate supervision and guidance, develop novel analyses and reports
- 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.
- 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.
- Partner with the HEDIS data team, Clinical Quality Analytics and Medical Record Review teams to support HEDIS performance improvement initiatives.
QualificationsYour Knowledge and Experience - Requires a bachelor's degree in health science, quantitative social science, public health, health services research or business or equivalent experience.
- MPH, MBA, MS, MA, RN, or RHIA in health science, quantitative social science, public health, health services research or business preferred. 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 (e.g. Tableau, Power BI) or task management tools (e.g. JIRA, Work Front, SharePoint) or cloud data (e.g. Azure, AWS, Snowflake) preferred.
- Experience working with RDBMS: Oracle, Netezza, DB2 etc. preferred.
- 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 government payer)
- Requires at least 3 years of experience working with NCQA HEDIS quality measures.
- Experience utilizing a 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)
About the TeamAbout Blue Shield of CaliforniaAs of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values: - Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model:At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
- Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
- On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity:External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
