This position supports and executes the Healthcare Effectiveness Data and Information Set (HEDIS) data quality strategy for optimal HEDIS submission to National Committee for Quality Assurance (NCQA). Responsibilities include oversight of the HEDIS portal, QCR data profiling and HEDIS reporting. Will work cross functionally coordinating and driving quality performance amongst all stakeholders. As a subject matter expert possesses extensive knowledge of HEDIS technical specifications assisting Plans and vendors with data improvement strategies to optimize QCR service charge. Carries out extensive data mining and analyses utilizing analytic tools and applications to identify opportunities for performance improvement in all aspects of HEDIS operations.
Responsibilities include but are not limited to:
- Clinical Quality Technical Strategy: Develop, communicate, and monitor quality performance standards for plans and the Federal Employee Program, while creating a year-round HEDIS data strategy focusing on PDR integration, QCR measures, and reporting. Continuously analyze data to improve HEDIS operations, ensure systems meet changing requirements, and educate teams on annual technical changes.
- Clinical Quality Technical Operations: Support end-to-end testing for compliance and efficiency improvements, leveraging application architecture and maintaining reference materials for continuous feedback. Communicate with business partners to optimize data, address defects, and implement resolutions.
- Clinical Quality Business Operations: Create and deliver presentations, reports, and summary materials, while supporting project management and implementation. Collaborate with partners and prepare content for conferences to ensure accurate system and process execution.
- Clinical Quality Assurance: Develop accurate HEDIS processes and maintain relationships with Quality departments and teams to support HEDIS reporting. Resolve complex data issues, ensure analysis integrity, and create methodology documents.
The posting range for this position is:
127,500.00 - 184,875.00Required Education, Certifications and Experience:
Education:
- Required Bachelor's Degree ; or equivalent experience
Experience:
- Required 7+ Years within a business environment, a managed care or health services delivery setting with expertise in health care operations, claims processing, and healthcare informatics
Knowledge Skills and Abilities:
- Excellent communication (written and oral) and interpersonal skills with an ability to communicate to small and/or large audiences (both internal and external to BCBSA)
- Advanced analytic skills with the ability to analyze and interpret data through complex analysis.
- Demonstrate curiosity and determination in pursuing complex and innovative approaches to data analyses.
- Knowledge of SAS, SQL, Cognos, or MCSource.
- Demonstrated ability to apply strong analytic / financial skills, with the knowledge of applications and technology commonly used in health care (e.g., clinical, administrative, financial, consumer, business intelligence, data integration, privacy and security)
Certifications & Licenses:
- Preferred: Legal, Risk, Contracts & Governance\AHIP - Professional, Academy for Health Care Management (PAHM)
- Preferred: Healthcare / Insurance\AHIP - Managed Healthcare Professional (MHP)
Additional Preferred Experience:
- Five or more years of experience within a business environment, a managed care or health services delivery setting with expertise in health care operations, claims processing, and healthcare informatics
- Experience with quality measurement experience (to include HEDIS measures and clinical quality)
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The posted salary range is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate’s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonus incentive pay.
We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
Skills Required
- Bachelor's degree or equivalent experience
- 7+ years experience in managed care, health services delivery, or healthcare operations
- Expertise in claims processing and healthcare informatics
- Knowledge of SAS, SQL, Cognos, or MCSource
- Advanced analytic skills; ability to analyze and interpret complex data
- Excellent written and oral communication and interpersonal skills
- Ability to apply analytic/financial skills and knowledge of healthcare applications and technology
- Experience with HEDIS measures and clinical quality (preferred)
- Preferred certifications: AHIP Professional, PAHM, Managed Healthcare Professional (MHP)
What We Do
Blue Cross Blue Shield Association is a national federation of 34 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide health care coverage for one in three Americans. BCBSA provides health care insights through The Health of America Report series and the national BCBS Health Index.
