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
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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.
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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.
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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.
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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.
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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.
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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.
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Ensure the accuracy, completeness, and reliability of data utilized in quality management and support downstream reporting, audit, analytics, and regulatory submissions.
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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.
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Analyze HEDIS production data trends, including membership growth/attrition, claims lag, encounter volumes, vendor submissions, and supplemental data performance, providing actionable recommendations to leadership.
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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
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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.
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Partner closely with ETL and Data Engineering teams to define requirements validate transformations, troubleshoot production issues, and ensure delivery of reliable HEDIS data assets.
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Support HEDIS audits by validating source data, responding to auditor requests, documenting data lineage, and ensuring readiness of both traditional and supplemental data sources.
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Maintain detailed documentation of data flows, mappings, transformation rules, vendor dependencies, and production processes to support knowledge transfer, governance, and audit readiness.
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Validate annual HEDIS software upgrades, specification updates, vendor enhancements, and data source changes to ensure production readiness and measure integrity.
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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.
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.
$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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