Job Description

Job Description Summary:

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:

113,007.88 - 152,825.99

Required 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 & GovernanceAHIP - Professional, Academy for Health Care Management (PAHM)
• Preferred: Healthcare / InsuranceAHIP - 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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