Job Description

Your Role

The Healthcare Quality Affordability (HQA) Analytics team plays a key role in discovering information hidden in vast amounts of data that can lead to smarter decisions and deliver better service for our customers and contain the rising cost of healthcare. The Medical Informatics, Consultant will report to the Manager of HQA Analytics. In this role you will be supporting Utilization Management Operations, with a strong emphasis on post-service analysis to assess cost of healthcare outcomes, identify opportunities for improvement, and inform decision-making. You will also lead the transformation of complex post service data into structured, high-quality datasets and actionable intelligence, enabling effective operational oversight and continuous performance optimization.

Responsibilities

Your Work

In 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 Medical Informatics Analysts at lower levels
• Produce analysis of high complexity under the guidance and direction of Medical Informatics Analyst V, supervisor 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
• Develop and maintain analytics reporting surrounding clinical authorization and post-service review, ensuring compliance with medical policies and regulatory requirements with institutions such as DMHC, CMS, NCQA, etc.
• Serve as a key liaison with vendor partners to oversee clinical authorization and post-service processes, ensuring data integrity, operational alignment, and timely resolution of discrepancies within the data
• Build and maintain robust data models for authorization data, integrating multiple data sources (e.g., UM, claims, vendor feeds) and ensuring alignment with business rules, data quality standards, and reporting requirements

Qualifications

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires SAS Certified Base Programmer Credential or equivalent and SAS Certified Advanced Programmer Credential or equivalent
• Requires at least 7 years of prior relevant experience
• Requires at least 5 years of experience in Health Care (managed care, academic, or gov't payer)
• Requires at least 2 years in one or more dashboard/BI tools, such as Power BI or Tableau.
• Strong understanding of data modeling concepts, and experience with SQL for data extraction, transformation, and validation. Familiarity with data transformation tools such as DBT and Power Query.
• Experience with Utilization Management, Financial, and/or Claims data, with knowledge in prior authorization, retrospective authorization, and/or post-service review strongly preferred.

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 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.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• 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.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

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.