Clinical and Quality Decision Support Consultant

at Highmark Health in Augusta, Maine, United States

Job Description

Company :


Job Description :


This position will utilize technical, analytical and business expertise in the design, development and support of various projects and data analysis of a complex nature. Advise and consult on issues regarding Enterprise Informatics strategy, business relationships, impact of other Highmark business decisions on Informatics, personnel utilization and the use of and planning for technology. The position will execute all facets of the Informatics project management process and additionally be able to lead multiple project managers. The incumbent may be required to mentor or supervise lower-level analysts through all stages of project design and analysis. Utilize advanced technical skills, understanding or core business units, the processes of those units, and the relevant data flows underlying the business processes in the preparation and analysis of large, complex data sets.

Utilizes advanced knowledge of corporate systems and data sources used by Highmark business units and a general understanding of the data flows generated by corporate systems (i.e. those supporting claims, billing, lab and Rx business processes) in the preparation and analysis to solve complex issues and problems. The incumbent must understand the terminology, techniques, and reimbursement mechanisms employed in the delivery of healthcare, both within the healthcare industry as well as within Highmark.


+ Consultation

+ Provide insight into Enterprise Informatics analyses and provide consultative guidance to Highmark partners .

+ Key business contact throughout numerous business units that may assist in the resolution of issues or problems.

+ Access, review, utilize, contribute content to and participate in the maintenance of the shared Enterprise Informatics Intellectual Capital Repository to include but not limited to, review/editing of content submissions and best practices, audit reports, etc. The incumbent is expected to make major contributions to the Repository.

+ Performs Enterprise Informatics liaison advocacy for emerging areas of Highmark business and leads support liaison advocacy on behalf of selected Highmark business areas. Advocacy involves the representation of the business partner’s critical business objectives when prioritizing new work requests vis-à-vis existing workload and resource commitments

+ Provide overall technical direction (analytic and/or computing) of complex projects to creatively implement effective decision support applications and consultation on the design, testing, and enhancement of reporting systems. Recommends improvement to plan design

+ Provides feedback to various areas in order to improve service delivery and enhance program design efforts.

+ Develop and foster relationships across Highmark and with professional organizations, user groups and industry trade groups to stay current with technology and analysis methods

+ Modeling & Methodologies

+ Work independently or leading a multidisciplinary team, designs and implement new analytic models and methodologies of a complex nature for profiling providers, assessing patient outcomes, studying cost and utilization trends and quantitative projections of industry and competitor performance, and conducting other general decision support activities

+ Lead special complex studies, computer simulations, statistical testing and projects to solve unique problems/questions identified by middle/senior management, business partners, coalitions and governmental agencies. These studies and projects may involve all aspects of the health insurance business and care management processes and may be confidential in nature or for public dissemination.

+ Performs or leads staff in the development and maintenance of highly complex computer programs using 4GL programming languages and other advanced database/SQL technology, statistical modeling, system testing activities, lead initial problem identification and resolution activities, maintains program/system documentation and prepares/maintains operations documentation for assigned applications.

+ Utilize or lead the integration of data obtained from external sources such as HC4, HMS, Medco, Acxiom, NCQA, and BCBSA with internal Highmark data. This position routinely utilizes data including, but not limited to: medical/surgical physician and institutional claims and encounters, clinical data, prescription drug data, membership data, dental and vision claims, provider data, financial data (i.e., revenue, premium, billing, pricing) and a variety of external normative and benchmark data.

+ Lead the evaluation and selection of new complex clinical and technical products and methodologies necessary to enhance current capabilities and positively impact corporate performance

+ Researches, manipulates, and prepares data related to Health Management programs that document program activities and the results of Health Management interventions and initiatives.

+ Project Management

+ Execute all facets of the Informatics project management process and lead multiple project managers.

+ Independently complete problem definition, requirements gathering, analysis design, statistical testing, results interpretation, and presentation of findings (online, written or verbal).

+ Independently ensure that the resulting methodologies/processes/software systems are compatible with the corporate technology architecture and is responsible for planning and managing the ISG implementation of the new function/object into the production processing environment.

+ Identification of parallel issues and project needs in medical and/or business literature

+ Other duties as assigned or requested.



+ Bachelor’s Degree in Analytics, Marketing, Computer Information Systems, Computer Science, or closely related discipline

+ 5-10 years experience in support of a Marketing function or Data Analyst role or in a business environment with responsibility for application of technology in the solution of business problems.

+ 5-10 years experience in querying relational databases utilizing 4GL programming languages such as: SAS and SQL.

+ 5-10 years experience performing project management activities, such as

+ Problem identification

+ Meeting project standards and deadlines

+ Collection of sufficient & accurate information


+ Demonstrated strong programming skills, with an emphasis on the utilization of SAS and SQL, or comparable 4GL programming language, in querying relational databases.

+ Demonstrated understanding of relational databases and normalization schema, data source availability, interpretation of field elements, their application and interrelation and file structures and system requirements necessary in accessing information and in investigating and attempting to resolve data anomalies.

+ Strong knowledge of other Highmark business areas, their processes and data flows as they impact analyses performed by Informatics, including knowledge of file structures, system requirements, processes and functionality.

+ Demonstrated advanced skills and experience using sophisticated analytic techniques and tools to solve complex problems and reveal insights derived from data analysis not readily apparent through the application of more standard techniques and tools.

+ Demonstrated ability to concurrently perform multiple complex tasks as directed or as needed, in a manner that maximizes productivity.

+ Demonstrated strong written and verbal communication skills with an emphasis on management-level consultative customer service, conflict resolution, interpersonal and group/meeting presentations or participation in meetings involving technical, non-technical and customer associates or audiences.

+ Strong understanding of the terminology, techniq

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Job Posting: JC251533169

Posted On: Nov 22, 2023

Updated On: Feb 04, 2024

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