Senior Claims Quality
2 weeks ago
Your 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.
Your Work
In this role, you will:
Conduct independent analysis of high complexity under moderate supervision and guidance, develop novel analyses and reports
Develop documentation and create and execute workplans for analyses of high complexity
Produce analysis of high complexity under the guidance and direction of Clinical Quality Analyst – Consultant or Principal or Manager
Design, build, and enhance data systems and applications so that they better serve specific reporting requirements
Identify business risks relating to report design and production
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
Produce monthly provider and/or employer group specific reports based on HEDIS measures in alignment with reporting quality ratings systems such as NCQA Stars/Accreditation, Medicare Stars, Medi-Cal Managed Care Accountability Sets, Quality Transformation Initiative and Quality Rating System
Partner with the HEDIS data team, Clinical Quality Analytics and Medical Record Review teams to support HEDIS performance improvement initiatives
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
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)
Preferred experience with visual management (eg. Tableau, Power BI) or task management tools (eg. JIRA, Work Front, Sharepoint) or cloud data (eg. Azure, AWS, Snowflake)
Preferred- 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 to 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.
Pay Range:
The pay range for this role is: $ 99000.00 to $ 148500.00 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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