The Enterprise Retrospective Chart Review team oversees end to end retrospective coding operations, ensuring the accuracy, completeness, and compliance of medical record review across all risk adjusted lines of business. The team manages enterprise workflows, vendor performance, coding quality, audit readiness, and cross functional alignment with Clinical, Compliance, and Risk Adjustment partners.
In this role, you will:
Analyze under the supervision of the core principles and functionality of decision and descriptive analytics including analyzing historical data, past performance and trends
Develop and run programs that apply to analytic decision techniques
Contribute to successful programs for the team, engaged in typically one area related to vendor oversight, internal cross functional partnerships, tracking performance and measuring results
Continuously learn about plan data including claim, premium, membership, and risk score assignment
Conduct data analysis, documenting and verifying the assumptions used in computations such as those used in member risk data and score submissions and establishing revenue accruals
Analyze operational performance to identify trends, risks, and improvement opportunities and to forecast retrieval volumes, coding workloads, and capacity needs using both traditional analytics and AI‑driven modeling
Design AI‑enabled workflows that enhance chart ingestion, data validation, and operational reporting for risk adjustment, using AI tools to improve efficiency and consistency
Automate data processes by building Python and SQL solutions and applying AI applications to streamline vendor file processing, recurring reporting, and ad hoc analytics
Produce operational reporting through dashboards and scorecards that summarize retrieval performance, coding outcomes, and risk adjustment trends, supported by AI‑assisted insight generation
Manage data quality by ingesting weekly vendor data loads, performing QA checks, validating accuracy, and applying AI tools to support anomaly detection and data review
Requires a bachelor’s degree in health management, mathematics, statistics, computer science, or a related field
Requires 3+ years of experience building reproducible analytic pipelines (end-to-end data workflows from raw extraction to structured reporting) and technical documentation using SQL, SAS, or Python on health plan data (claims, premium, and membership).
Requires experience building dashboards or visual reports that support operational decision making
This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
Blue Shield of California strives to create a healthcare system worthy of its family and friends that is sustainably affordable. The health plan is a tax paying, nonprofit, independent member of the Blue Shield Association with nearly 6 million members, over 7,500 employees and more than $25 billion in annual revenue.
Founded in 1939 in San Francisco and now headquartered in Oakland, Blue Shield of California and its affiliates provide health, dental, vision, Medicaid and Medicare healthcare service plans in California. The company has contributed more than $60 million to Blue Shield of California Foundation in the last three years to have an impact on California communities.
For more news about Blue Shield of California, please visit news.blueshieldca.com.
