RESPONSIBILITIES

• Provide analytical leadership to develop methodologies and approaches necessary to support the Clinical Care process
• Lead the team in designing and performing in depth statistic/quantitative analysis of healthcare claims and utilization data in order to identify appropriate members for the various clinical care programs. Also measure outcomes and effectiveness of each program
• Work with Clinical Care Leadership to improve results and efficiencies of each program
• Develop and update predictive models and include member stratification and gaps in care
• Work with the sales area to demonstrate the effectiveness of our clinical value to our customers
• Integrate pharmacy and behavioral claims data into the various analyses to improve effectiveness of current programs or develop new clinical programs
• Collaborate with a cross functional workgroup (Care, Network Pharmacy, Product, Quality Improvement, etc.) to identify interventions and transition to implementation
• Communicate analytical results with key internal customers and cross-functional stakeholders (Care, Pharmacy, Network, Finance, Retail Health, Quality Improvement, etc.)
• Enable efficient and effective care patterns related to quality, use and cost of healthcare services. Identify variances in treatment patterns by condition
• Extract and process data from various internal and external as appropriate to incorporate into the analyses
• Assist in training and development of staff

REQUIREMENTS

• Bachelor's degree or equivalent work experience
• 10 or more years' experience in health insurance and operational positions in various healthcare venues
• Experience with data analytics to include data extraction, predictive modeling, and gap analysis
• Experience building relationships with key stakeholders (e.g. BCBSF leadership, Medical Societies and Associations)
• Management experience to include experience developing, mentoring, and transferring knowledge and skills to staff
• Knowledge of clinical operations
• Knowledge of healthcare insurance benefits and managed care programs
• Demonstrated experience in planning and execution of complex business and organizational issues to effect change
• Demonstrated communication skills, as incumbent will routinely be called upon to meet and conduct presentations with professional physician/provider associations

PREFERENCES

• Master's in Healthcare Administration, Public Health, Epidemiology, or Statistics
• Knowledge of current events that affect the insurance industry to include State regulations
• Benchmarking and research principles, practices and methodologies.
• Demonstrated use of the tools and principles of continuous improvement
• Understanding of BCBSF organization, structure, policies and procedures
• Understanding of provider networks, pricing and reimbursement methodologies

HOW TO APPLY

POLICY