Job Description

Your Role

The AI & Analytics (AI&A) team sits within the enterprise Growth organization, specifically aligned to the Risk Adjustment vertical. While situated within Risk Adjustment, this is strictly an advanced Medical Informatics and data architecture role. The Consultant will serve as a critical semantic bridge and analytical lead supporting the Individual & Family Plan (IFP) Line of Business under the Government Markets Organization.

Reporting to the Sr Manager of Medical Informatics, this role is responsible for acting as an AI & Analytics partner to key leaders and cross-functional stakeholders across IFP, Actuarial, HQA, Network Operations, and Finance to achieve their Growth-related business objectives. The successful candidate will act as "two-in-a-box" collaborator to share LOB Membership Retention & Growth goals, and Covered CA regulatory reporting, translate complex business problems into structured analytical approaches, design smart analytical tools, and leverage internal data structures to uncover CoHC optimization and member acquisition opportunities.

Responsibilities

Your Work

In this role, you will:

• Use deep understanding of underlying business requirements to conceptualize and develop analytical systems that meet important business needs
• Design and develop these systems so that they can be used by lower-level analysts thereby promoting company-wide efficiencies
• Lead the architectural transition of legacy, on-premise analytic workflows and data pipelines into modern, cloud-native environments, utilizing Databricks, Snowflake, and other enterprise-governed cloud tools to ensure scalable, automated business logic.
• Coordinate activities with other internal departments to maximize overall efficiency and resolve conflicts
• Communicate project status, progress, and outcomes to executive management
• Fulfill a leadership role in the critical review and ongoing development of data management and analytical systems for strategically important enterprise-wide analysis and reporting
• Serve as a technical mentor by reviewing SQL, SAS, and Python code of junior staff while working independently to drive complex portfolios forward with limited supervision. Integrate AI-assisted development tools (such as GitHub Copilot) into daily coding workflows to accelerate deployment timelines, enhance code quality, and support automated pre-peer-review safety nets. Be adept at creating new reusable assets
• Lead complex medical claims analysis to support Cost of Health Care (CoHC) analytics, dissecting trends, cost drivers, and billing methodologies to identify optimization and recover opportunities
• Design, develop, and optimize Tableau dashboards and self-service reporting tools, including broker-facing performance and membership dashboards, translating business requirements into scalable reporting solutions that improve visibility into sales, enrollment, retention, and operational metrics
• Support Covered California Transparency in Coverage (TiC) reporting and compliance initiatives by coordinating data collection, validating source-to-target lineage, documenting transformation logic, facilitating stakeholder review and sign-off processes, and producing auditable regulatory submission deliverables
• Improve member retention & conversion rates by collaborating with business partners to design and report from outreach tracking systems (e.g., PEGA, Salesforce) and conduct plan cost/value studies.
• Improve Acquisition by leveraging data from Markets, Provider, Geo, and Operations tracking to target and execute strategies that drive multi-product growth as customers transition through different life stages
• Identify drivers of membership both internally and externally, as well as conversions from one product to another as customers transition through different life stages

Qualifications

Your Knowledge and Experience

• Requires a bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree . Master's degree preferred
• Requires 7 years of relevant experience delivering healthcare analytics (cost, quality, utilization, and/or outcomes)
• Requires 5+ years advanced experience working with complex Medical Claims, Membership and Provider data architectures
• Requires advanced coding proficiency in SQL & Python, with strong applied experience in SAS and a working knowledge of modern cloud-native data stacks (Snowflake, Databricks, RDBMS etc.) for pipeline automation
• Requires familiarity with AI coding assistants (e.g. GitHub Copilot, Codex) or a strong, demonstrated willingness to quickly learn and adopt AI tooling to optimize engineering efficiency
• Requires deep domain fluency with IFP lines of business (On Exchange, Off Exchange, Covered CA Small Business) and standard enrollment and claims data structures
• Requires high degree of fluency with PEGA, Salesforce and similar enterprise CRM/outreach applications
• Requires high degree of proficiency with interpersonal communication, verbal/written presentations, math, analytical problem-solving, and the ability to adapt quickly to shifting or competing priorities

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

About the Team

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.