Your Role

The Clinical Quality Measurement team manages HEDIS annual submissions and other quality measure submissions to CMS, NCQA, DHCS and other governing bodies. The Medical Informatics Analyst, Consultant will report to the Sr Manager, Medical Informatics. In this role You will support corporate and departmental strategies and goals for the annual HEDIS submission process and effectively apply business knowledge and technical expertise to support the business initiatives to report clinical quality of care received by members. You will collect data from various internal systems (examples: Claims processing or membership systems) and external systems (EMR/EHR) and convert those data into actionable insights to guide business decision making for BSC population health management and quality of care. You will also support lower level analysts on programming and business knowledge acquisition.

Your Work

In this role, you will:

• Conduct independent analysis of high complexity and develops reports independently Develop analytical methods so that they may be subsequently delegated for production to Medical Informatics Analysts at lower levels
• Communicate analytical results in graphs or summaries to various stakeholders.
• Develop documentation and create and execute workplans for analyses of high complexity.
• Prepare presentation materials that clearly convey information to appropriate internal and external Blue Shield audiences
• Provide training and mentoring for team members on best practices for analysis and Reporting
• Review and revise existing analytical processes for accuracy and efficiency. Identify existing inefficiencies and problems and take action to implement solutions
• Continuously refine and expand the technical, clinical, and financial content knowledge required to successfully complete these duties
• Develop, implement, and document quality assurance (QA) processes to ensure that reported data is accurate and reliable
• Recommend and implement solutions for identified problems/root cause pertaining to clinical data used for HEDIS reporting
• Assist junior team members through peer review, informal training, or mentoring
• Contribute to team success by accomplishing tasks as needed

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. Preferred a MPH, MBA, MS, MA, RN, or RHIA in health science, quantitative social science, public health, health services research or business, or BA/BS with demonstrated equivalent work experience
• Requires SAS Certified Base Programmer Credential or equivalent and SAS Certified Advanced Programmer Credential or equivalent
• 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
• 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
• Superior analytical skills required.
• Experience working with Clinical Quality data
• Experience working with RDBMS: Oracle, Netezza, DB2 etc.
• Ability to document processes. Excellent technical, interpersonal, written and oral communication skills required.
• Proficient in MS Office- Word, Excel and PowerPoint
• 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
• Requires 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)
• Individual should be self-starter motivated to correctly interpret business needs, possesses strong problem-solving skills, as well as technical expertise needed to do hands-on data analysis, research and programming work.
• Experience and ability to utilize a certified HEDIS software.
• Experience developing dashboard in Tableau is a plus

Pay Range:

The pay range for this role is: $ 118800.00 to $ 178200.00 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.

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