Resp & Qualifications

PURPOSE:

The Quality Analyst supports HEDIS, Stars, regulatory, quality improvement, and population health initiatives across lines of business by retrieving and reviewing medical records, analyzing quality data, supporting audit readiness, and operationalizing initiatives that improve care quality, member experience, gap closure, and population-level outcomes.

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:

• Coordinate medical record retrieval, provider outreach, intake, upload, routing, follow-up, and documentation activities for HEDIS, Stars, quality performance, regulatory reporting, Risk Adjustment support, and assigned Quality initiatives. Validate provider/facility information, document outreach efforts, escalate barriers, and ensure records are received from the appropriate provider group and assigned to the correct project.
• Perform medical record abstraction, research, and quality review by applying current HEDIS and NCQA measure specifications, company training guidelines, and project requirements.
• Accurately document findings, create and resolve routine pends, support discrepancy resolution, and maintain productivity, turnaround, accuracy, and quality expectations.
• Support audit readiness and data integrity activities, including primary source verification for supplemental data, record and invoice review related to medical record retrieval projects, validation of receipt and project assignment, reconciliation of missing or incomplete documentation, and maintenance of compliant documentation for internal and external review.
• Analyze workflow, quality, productivity, and measurement trends to identify improvement opportunities, support targeted retrieval and gap-closure strategies, prepare actionable reports or summaries, and collaborate with internal teams, vendors, and provider-facing partners to improve HEDIS and quality outcomes across lines of business.
• Maintain subject matter knowledge of HEDIS, NCQA, CMS quality standards, accreditation expectations, medical record review processes, HIPAA requirements, and quality operations. Support development and maintenance of training materials, standard operating procedures, job aids, workflow documentation, and cross-training resources; perform other duties as assigned.

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:

• RN-BC - Certified General Nursing Practice.

Experience: 3 years professional experience in a business environment (public health, health insurance, management consulting fields preferred); evidence of progressing levels of responsibility.

Preferred Qualifications:

• Certification in Quality or Process Improvement Methods preferred.
• Direct experience with HEDIS, NCQA accreditation, CAHPS, CMS quality programs, Stars, quality improvement, regulatory reporting, or related quality activities in a healthcare, managed care, payer, provider, or HEDIS vendor environment.
• Data analytics experience working with healthcare data, large data sets, dashboards, trackers, or reports to answer clinical, operational, quality, or business questions.
• Experience with medical record retrieval, provider outreach, medical record abstraction, overread or quality review, pend research, supplemental data, primary source verification, and audit readiness workflows.
• Experience applying HEDIS measure specifications and medical record review guidelines to support accurate gap closure, reporting, supplemental data use, and quality performance improvement.
• Experience using Microsoft Office tools and web-based applications; familiarity with HEDIS or medical record review platforms such as Cotiviti, Inovalon, Reveleer, or similar systems preferred.
• At least two consecutive HEDIS seasons with the same company preferred.

Knowledge, Skills and Abilities (KSAs)

• Expertise in qualitative and quantitative data analyses and presentations
• End-to-end experience designing, developing, and implementing innovative strategies to improve population health.
• Ability to conduct advanced analytics using SQL, Python, R, or similar.
• Fluent in the use of Microsoft tools including Excel, Word, Power Point and Outlook.
• Knowledge of healthcare claims, survey, clinical, and health data.
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.
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Travel Requirements
Estimate Amount: 15%

Salary Range: $63,576 - $126,269

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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