Resp & Qualifications
PURPOSE:
The Senior Quality Analyst is responsible for the most complex work of the team in defining, measuring, analyzing, and evaluating population health, while prioritizing, developing, and operationalizing innovative initiatives to improve the quality of care and experience, resulting in industry-leading outcomes at a population level. Independently responsible and accountable for ensuring that their work aligns with and helps to achieve the organization's vision as it relates to population health, quality, and member experience. Serves as peer mentor within the team.
We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.
ESSENTIAL FUNCTIONS:
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Act as a senior subject matter expert in HEDIS, population health, measurement science, NCQA accreditation, quality programs, Stars, medical record review, supplemental data, primary source verification, and quality improvement. Utilize NCQA and HEDIS technical specifications, quality standards, and internal Quality Department guidelines to complete and document work products in support of compliant reporting, audit readiness, and quality performance improvement.
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Lead and support complex medical record retrieval, provider outreach, intake, routing, upload, documentation, abstraction, overread, quality review, and pend research activities for prospective and retrospective HEDIS projects, Stars initiatives, Risk Adjustment support, supplemental data validation, and other quality or regulatory initiatives. Validate provider and facility information, confirm records are received from the appropriate provider group, ensure records are assigned to the correct project, resolve complex retrieval or documentation issues, and escalate provider or vendor barriers as needed.
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Analyze and evaluate workflow outcomes, retrieval progress, abstraction accuracy, pend trends, data integrity findings, productivity, quality results, and measure-level opportunities using qualitative and quantitative methodologies. Produce actionable reports, summaries, visualizations, and recommendations that support targeted gap closure, audit readiness, supplemental data use, operational improvement, and improved quality outcomes across Commercial, Medicare, Medicaid, ACA, FEP, and other assigned lines of business.
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Prioritize, develop, and operationalize quality improvement opportunities in collaboration with internal Quality teams, analytics partners, provider-facing teams, vendors, and other business areas. Support the standardization of retrieval, abstraction, overread, reconciliation, PSV, vendor management, training, and documentation workflows to improve accuracy, timeliness, compliance, continuity, and scalability across HEDIS and quality operations.
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Mentor team members and provide guidance on complex work efforts, including HEDIS measure interpretation, medical record review, pend resolution, provider outreach, audit documentation, workflow troubleshooting, and issue escalation. Develop and maintain standard operating procedures, job aids, training materials, trackers, workflow documentation, and reference tools. Assist with special projects and department initiatives requiring thought leadership, subject matter expertise, cross-functional coordination, and consultative support.
SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS:
Education Level: Bachelor's Degree in population health, public health, healthcare administration, business administration, health policy, economics, statistics, mathematics, data science, or a related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications Preferred:
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RN-BC - Certified General Nursing Practice
Experience: 5 years professional experience in a business environment (public health, health insurance, management consulting fields preferred); evidence of progressing levels of responsibility.
Preferred Qualifications:
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Certification in Quality or Process Improvement Methods preferred.
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Direct experience with HEDIS, NCQA accreditation, CAHPS, quality programs, Stars, quality improvement, or related quality activities in a healthcare, managed care, payer, provider, or HEDIS vendor environment.
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Data analytics experience working with large data sets to answer clinical, operational, or business questions; prior experience with healthcare data expected.
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Experience interpreting and applying HEDIS measure specifications, NCQA requirements, medical record review guidelines, and audit documentation expectations to support accurate gap closure, reporting, supplemental data use, and quality performance improvement.
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Experience monitoring productivity, quality, retrieval, abstraction, overread, outreach, pend management, or project trends to recommend workflow improvements, escalation, training, operational strategies, supplemental data validation, primary source verification, and audit-readiness workflows.
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Experience developing or maintaining SOPs, job aids, workflows, trackers, training materials, reference tools, or audit documentation, and mentoring or cross-training peers during quality, HEDIS, medical record retrieval, or medical record review initiatives.
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At least two consecutive HEDIS seasons with the same company preferred.
Knowledge, Skills and Abilities (KSAs)
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Expertise in qualitative and quantitative data analyses and presentations.
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End-to-end experience designing, developing, and implementing innovative strategies to improve
population health. -
Experience self-managing multiple projects and provide regular status reports.
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Ability to conduct advanced analytics using SQL, Python, R, or similar.
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Fluent in the use of Microsoft tools including Excel, Word, Power Point and Outlook.
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Expertise with healthcare claims, survey, clinical, and health data.
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Ability to mentor and guide other team members and lead initiatives in a matrix environment.
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Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $72,432 - $143,858
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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