Medical Informatics Analyst, Consultant

Consultant, AI & Analytics The AI & Analytics (AI&A) team sits within the enterprise Growth organization, specifically aligned to the Risk Adjustment vertical. While situated within Risk Adjustment, this is strictly an advanced Medical Informatics and data architecture role. The Consultant will serve as a critical semantic bridge and analytical lead supporting the Individual & Family Plan (IFP) Line of Business under the Government Markets Organization. Reporting to the Sr Manager of Medical Informatics, this role is responsible for acting as an AI & Analytics partner to key leaders and cross-functional stakeholders across IFP, Actuarial, HQA, Network Operations, and Finance to achieve their Growth-related business objectives. The successful candidate will act as "two-in-a-box" collaborator to share LOB Membership Retention & Growth goals, and Covered CA regulatory reporting, translate complex business problems into structured analytical approaches, design smart analytical tools, and leverage internal data structures to uncover CoHC optimization and member acquisition opportunities.

Serve as a technical mentor by reviewing SQL, SAS, and Python code of junior staff while working independently to drive complex portfolios forward with limited supervision. Integrate AI-assisted development tools (such as GitHub Copilot) into daily coding workflows to accelerate deployment timelines, enhance code quality, and support automated pre-peer-review safety nets. Be adept at creating new reusable assets Lead complex medical claims analysis to support Cost of Health Care (CoHC) analytics, dissecting trends, cost drivers, and billing methodologies to identify optimization and recover opportunities Design, develop, and optimize Tableau dashboards and self-service reporting tools, including broker-facing performance and membership dashboards, translating business requirements into scalable reporting solutions that improve visibility into sales, enrollment, retention, and operational metrics Support Covered California Transparency in Coverage (TiC) reporting and compliance initiatives by coordinating data collection, validating source-to-target lineage, documenting transformation logic, facilitating stakeholder review and sign-off processes, and producing auditable regulatory submission deliverables Improve member retention & conversion rates by collaborating with business partners to design and report from outreach tracking systems (e.g., PEGA, Salesforce) and conduct plan cost/value studies. Improve Acquisition by leveraging data from Markets, Provider, Geo, and Operations tracking to target and execute strategies that drive multi-product growth as customers transition through different life stages Identify drivers of membership both internally and externally, as well as conversions from one product to another as customers transition through different life stages QualificationsYour Knowledge and Experience Requires a bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree. Master's degree preferred Requires 7 years of relevant experience delivering healthcare analytics (cost, quality, utilization, and/or outcomes) Requires 5+ years advanced experience working with complex Medical Claims, Membership and Provider data architectures Requires advanced coding proficiency in SQL & Python, with strong applied experience in SAS and a working knowledge of modern cloud-native data stacks (Snowflake, Databricks, RDBMS etc.) for pipeline automation Requires familiarity with AI coding assistants (e.g. GitHub Copilot, Codex) or a strong, demonstrated willingness to quickly learn and adopt AI tooling to optimize engineering efficiency Requires deep domain fluency with IFP lines of business (On Exchange, Off Exchange, Covered CA Small Business) and standard enrollment and claims data structures Requires high degree of fluency with PEGA, Salesforce and similar enterprise CRM/outreach applications Requires high degree of proficiency with interpersonal communication, verbal/written presentations, math, analytical problem-solving, and the ability to adapt quickly to shifting or competing priorities HybridThis role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week. Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need. About UsAbout Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!