Clinical Quality Analytics, Senior - Blue Shield of California : Job Details

Job DescriptionYour 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. ResponsibilitiesYour Work Essential functions include but not limited to:

• Conducts analysis of moderate complexity and develops reports with guidance from managers and peers.
• Communicates analytical results in graphs or summaries to various stakeholders.
• Prepares presentation materials that clearly convey information to appropriate internal and external Blue Shield audiences.
• Designs, builds, and enhances data systems and applications so that they better serve specific reporting requirements.
• Assist in developing documentation for all new and existing SAS programs.
• Reviews and revises existing analytical processes for accuracy and efficiency.
• Identifies existing inefficiencies and problems and takes action to implement solutions.
• Assists junior team members through peer review, informal training, or mentoring.
• Seeks and provides advice to analysts in other departments and business units regarding standardization of business rules and methods for analysis and reporting.
• Produces accurate results under tight deadlines.
• Continuously refines and expands the technical, clinical, and financial content knowledge required to successfully complete these duties.
• Develops, implements, and documents quality assurance (QA) processes to ensure that reported data is accurate and reliable.
• Recommends and implements solutions for identified problems/root cause pertaining to clinical data used for HEDIS reporting.
• Provide advanced analytical support for business operations in all or some of the following areas: claims, provider data, member data, clinical data, HEDIS, pharmacy, or external reporting.
• Contributes to team success by accomplishing tasks as needed.

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.
• 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)

Additional Preferred

• Preferred experience with visual management (e.g. Tableau, Power BI) or task management tools (eg. JIRA, Work Front, Sharepoint) or cloud data (eg. Azure, AWS, Snowflake)
• Mastery of at least two of the following: clinical coding, large-scale health databases, health statistics (e.g., epidemiology or health services), health insurance business principles. Must have sufficient familiarity with the technical and clinical concepts necessary to adequately perform the duties described above.
• Experience developing SAS/SQL programs and scripts that can be passed on to other analysts to improve their work efficiency.
• Must be able to develop programs and scripts that can be used to repeatedly generate reliable reports and analytics.
• Strong verbal and written communication skills
• Must exhibit level-appropriate competence in Departmental competency dimensions (Communication, Agile Learning, Business Knowledge, Creativity, Critical Thinking, Customer Focus, Drive for Results).
• Capable of managing deadlines and working simultaneously on a variety of tasks.
• Experience with cost-of-healthcare or quality of care assessment in a managed care or academic setting
• Experience utilizing a certified HEDIS software.

About the Team About Blue Shield of California As 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.