Job Description
Utilizing strong functional/technical area knowledge and expertise with relevant systems/applications. The incumbent defines, evaluates, and validates requirements, business functional design, and technical design for complex business issues within their domain areas. They act as a liaison representing their department and the processes and workings within it to develop effective technical solutions and minimize operational and system/application impacts. Coordinates with IT to support problem resolution, testing, software upgrades and related projects of a more complex nature.This is a HEDIS Data Management and Production Operations role, not a Business Intelligence or reporting-focused position. The ideal candidate will have direct experience managing monthly HEDIS data loads, data quality validation, production support, vendor data integration, and cross-functional delivery of HEDIS initiatives in partnership with ETL and Data Engineering teams.
What You'll Do
- Serve as the primary data management lead for the monthly HEDIS production process, owning the end-to-end intake, loading, validation, reconciliation, and certification of HEDIS data from multiple internal and external sources.
- Demonstrate deep knowledge of the monthly HEDIS data load lifecycle, including claims, enrollment, pharmacy, provider, laboratory, EMR, supplemental, and vendor data ingestion processes, and ensure successful execution of monthly, quarterly, and annual production schedules.
- Develop and maintain SQL queries, data mappings, and integrations to support HEDIS quality metrics, including advanced data mapping across claims, clinical, vendor, supplemental, and FHIR-based data sources.
- Independently drive HEDIS data initiatives from requirements through implementation, partnering with IT, ETL, data engineering, vendors, and business stakeholders to ensure successful delivery of solutions.
- Perform monthly loading, validation, reconciliation, and monitoring of the HEDIS data management pipeline, ensuring timely and accurate ingestion of all required source data and proactive resolution of data quality issues.
- Lead data quality investigations and root cause analysis related to HEDIS rates, member eligibility, measure compliance, claims lag, supplemental data integration, and vendor feed discrepancies.
- Ensure the accuracy, completeness, and reliability of data utilized in quality management and support downstream reporting, audit, analytics, and regulatory submissions.
- Collaborate with cross-functional teams to define HEDIS data requirements and implement process improvements that expand and integrate new data sources, including vendor feeds, EMR data, digital quality measures, and FHIR APIs.
- Analyze HEDIS production data trends, including membership growth/attrition, claims lag, encounter volumes, vendor submissions, and supplemental data performance, providing actionable recommendations to leadership.
- Develop, test, and maintain processes supporting ingestion and management of supplemental clinical data sources, including EMR, Laboratory, CCDA, Immunization Registry, Medical Records, FHIR APIs, and vendor submissions
- Monitor and reconcile monthly vendor data loads to identify gaps, anomalies, unexpected volume changes, mapping issues, or data quality concerns; coordinate resolution efforts with vendors and internal technical teams.
- Partner closely with ETL and Data Engineering teams to define requirements validate transformations, troubleshoot production issues, and ensure delivery of reliable HEDIS data assets.
- Support HEDIS audits by validating source data, responding to auditor requests, documenting data lineage, and ensuring readiness of both traditional and supplemental data sources.
- Maintain detailed documentation of data flows, mappings, transformation rules, vendor dependencies, and production processes to support knowledge transfer, governance, and audit readiness.
- Validate annual HEDIS software upgrades, specification updates, vendor enhancements, and data source changes to ensure production readiness and measure integrity.
- Develop and maintain SQL queries, data mappings, and integrations to support HEDIS quality metrics, including strong data mapping skills across claims, clinical, vendor, and FHIR based data sources.
What You Bring
Bachelor's degree or advanced degree (where required)
5+ years of experience in related field
In lieu of degree, 7+ years of experience in related field
Proven experience as an Analyst, preferably in quality data management, HEDIS reporting, or a related healthcare analytics role.
Proficient in programming languages such as SQL, Python, R, or similar.
Experience with data management systems and tools (e.g., SQL databases, ETL tools, data visualization software).
Strong familiarity with FHIR standards (US Core, QICore), digital quality measure (dQM) interpretation, and robust data mapping across claims, clinical, and vendor data sources.
Experience performing recurring (monthly) data loads, monitoring production pipelines, and trend analysis across membership and claims data.
Strong analytical skills with attention to detail and ability to identify data anomalies, trends, and root causes.
Familiarity with quality control processes and standards (ISO, Six Sigma, etc.) is a plus.
What You’ll Get
The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
Work-life balance, flexibility, and the autonomy to do great work
Medical, dental, and vision coverage along with numerous health and wellness programs
Parental leave and support plus adoption and surrogacy assistance
Career development programs and tuition reimbursement for continued education
401k match including an annual company contribution
Learn more
Where You’ll Work
Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplace that’s flexible, connected, and future focused.
In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter.
Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.
Salary Range
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
Skills
Application Implementation, Best Practices Development, Business Process Improvements, Business Requirements, Business Requirements Analysis, Information Technology (IT) Projects, Information Technology Project Management, Requirements Gathering, Requirements Management, Technical Architecture_____________________________________________________________________
JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected].
Skills Required
- Bachelor's degree or advanced degree
- 5+ years of experience in related field
- In lieu of degree, 7+ years of related experience
- Proven experience as an Analyst in quality data management, HEDIS reporting, or healthcare analytics
- Proficient in SQL, Python, or R
- Experience with data management systems and tools (SQL databases, ETL tools, data visualization software)
- Strong familiarity with FHIR standards (US Core, QICore) and digital quality measure (dQM) interpretation
- Experience performing recurring monthly data loads, monitoring production pipelines, and trend analysis across membership and claims data
- Strong analytical skills with attention to detail and ability to identify data anomalies and root causes
- Familiarity with quality control processes and standards (ISO, Six Sigma)
What We Do
It's an exciting time to work at Blue Cross and Blue Shield of North Carolina. Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Our company is a not-for-profit with headquarters in Durham and major operations in Winston-Salem and Fayetteville. In all we employ more than 4,500 North Carolinians and serve more than 3.7 million customers. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives. Blue Cross NC is an independent licensee of the Blue Cross and Blue Shield Association.
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