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.
What You'll Do
Develop and maintain SQL queries, data mappings, and integrations to support HEDIS quality metrics, including strong data mapping across claims, clinical, vendor, and FHIR based data sources.
Perform monthly loading, validation, and monitoring of the entire HEDIS data management pipeline, ensuring timely and accurate ingestion of claims, enrollment, pharmacy, provider, and supplemental clinical data.
Ensure the accuracy, completeness, and reliability of data utilized in quality management, supporting downstream data extraction and reporting processes.
Collaborate with cross functional teams to define standard HEDIS data requirements and implement process improvements to integrate and expand new data sources, including vendor supplied feeds and FHIR digital quality measures (dQMs).
Analyze HEDIS and clinical related data trends, including membership growth/attrition, claims lag, encounter volumes, and vendor data patterns, and provide actionable insights to support informed decision making.
Develop, test, and maintain software programs and processes to manage quality data from various supplemental data sources (EMR, LAB, CCDA, Immunization Registry, Medical Records, FHIR APIs, and vendor submissions).
Monitor and reconcile monthly vendor data loads to identify gaps, anomalies, or unexpected changes in data volume, structure, or quality, and work with internal teams and vendors to resolve issues.
Conduct system testing, debugging, and documentation to maintain high quality standards and ensure accurate interpretation of HEDIS measures and FHIR digital measure logic.
Implement and maintain automated data management workflows and processes supporting monthly, quarterly, and annual HEDIS production cycles.
Ensure compliance with HEDIS regulatory standards, FHIR digital measure specifications, and internal quality control processes.
Partner with auditors and external stakeholders during the HEDIS audit process, addressing data requests and validating both traditional and vendor or FHIR derived datasets.
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.
WhatYou’llGet
The opportunity to work at thecutting edgeof health care delivery with a teamthat’sdeeply invested in the community
Work-life balance, flexibility, and the autonomy to dogreat work
Medical, dental, and vision coverage along withnumeroushealth and wellness programs
Parental leave and support plus adoption and surrogacyassistance
Career development programs and tuition reimbursement for continued education
401k match including an annual company contribution
WhereYou’llWork
Our Hybrid Flex approach is builton presencewith a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplacethat’sflexible, connected, and future focused.
In a Hybrid-Flex role,you’llwork in the office at least two days a week for collaboration and connection. In a Remote Flex role,you’llwork virtually, with a few in-office visits each year formeaningfulmoments 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 anystateslistedonthis 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.
$89,174.00 - $142,679.00
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
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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: HR.Staffing@BCBSNC.com
It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). 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.
Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.
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.
