Solutions and Data Analyst III

Job Summary

The Solutions and Data Analyst III serves as a Subject Matter expert (SME), technical and analytic integrator, responsible for designing, developing, and operationalizing advanced analytic solutions that drive strategic insight and organizational performance. This position combines strong data engineering fluency with analytical acumen transforming complex, multi-domain data (membership, encounters, providers, claims, quality metrics) into interpretable and actionable insights used by leaders across the health plan.

This position emphasizes the development of insight rich, production ready analytic assets, delivering repeatable, governed analyses that illuminate key drivers of care quality, efficiency, and financial outcomes. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.  

Duties

Designs and maintains reusable analytic data models and Extract, Transform, and Load (ETL) pipelines that support recurring insight generation and performance monitoring.

Leads development of advanced dashboards, reports, and analytic tools that surface trends, correlations, and performances opportunities across enterprise domains.

Partners with analysts, data scientists, and operational stakeholders to embed insights directly into workflows and decision processes.

Implements and maintains version control, peer review (pull request), and continuous integration practices for analytic codebases.

Ensures adherence to data lineage, governance, and reproducibility standards across all analytic products.

Supports enterprise level measure refresh cycles and ensures alignment with standardized data abstraction layers.

Drives continuous enhancement of the analytic ecosystem by integrating new data sources, improving data structures, and optimizing performance.

Translates analytic findings into business relevant narratives and partners with stakeholders to act on insights.

Applies subject matter expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Performs other duties as assigned.

Duties Continued

Domain Specific Experience and Skills:

Domain Focus: Authorization & Claims Operations Analytics
Required: Experience with Utilization Management (UM) authorization workflows and prior authorization metrics. Knowledge of claims operations, including receiving, adjudication, and provider dispute resolution. Knowledge of clinical and financial aspects of UM/claims and collaboration with operations or provider teams. Ability to analyze operational KPIs (e.g., turnaround times, denial rates, appeals outcomes) and translate data into actionable insights.

Domain Focus: Network Strategy Analytics

Required: Experience supporting initiatives to optimize cost, access, and quality within provider networks. Experience analyzing provider networks, including contracting, credentialing, and panel optimization. Ability to evaluate network performance metrics and translate findings into actionable insights for strategy and business planning.

Domain Focus: Risk Adjustment Analytics

Required: Experience with risk adjustment methodologies, including Hierarchical Condition Category (HCC) coding, hierarchical models, and member risk scoring. Knowledge of diagnosis documentation, encounter data, and coding completeness to optimize plan revenue and quality scores. Knowledge of regulatory requirements impacting risk adjustment (e.g., Centers for Medicare and Medicaid Services (CMS) guidelines). Ability to assess encounter submission and processing operations, identifying trends, anomalies, or gaps in risk capture across provider or member populations.

Preferred Certifications: AAPC Certified Risk Adjustment Coder (CRC®), Practice Management Institute Certified Risk Adjustment and HCC Coder (CRA-HCC™), NAMAS Certified HCC Coder (CHCC™), AHIMA Certified Coding Specialist (CCS®).
Domain Focus: Medical Cost Driver Analytics

Required: Experience analyzing medical cost drivers across populations, conditions, and service types. Experience developing dashboards or analytic tools to monitor and optimize medical spend. Knowledge of claims, provider, and condition level analyses to support financial and operational decision making. Ability to identify high-cost services, utilization patterns, and opportunities for cost containment.

Education Required

Education Preferred

Experience

Required:

At least 5 years of progressive analytics experience in healthcare, managed care, or related industries.

Proven experience designing, developing, and operationalizing analytic solutions across multiple domains.

Ability to operate with high autonomy, manage complex or ambiguous projects, and influence operational or strategic decisions.

Experience translating multi-domain analytics into actionable insights for leadership and enterprise-wide initiatives.

Demonstrated successful experience in communicating insights effectively to senior leadership and executives.

Preferred:

Experience with enterprise level initiatives, such as Key Performance Indicator (KPI) maintenance, cross-domain dashboards, measure ROI, or strategic investment analytics.

Strong experience managing care operations, including capitation, provider networks, risk adjustment, or quality incentive programs.

Skills

Required:

Expertise in designing, building, and maintaining complex ETL pipelines and analytic data models that support enterprise reporting, dashboards, and predictive insights. Advanced experience with BI tools (Tableau, Power BI) to design insight rich, production ready dashboards and analytic products. Proficiency with SQL and/or Python/R for large-scale data manipulation, advanced analyses, and operationalization of analytic workflows. Strong knowledge of version control (Git/GitHub) and CI/CD processes for analytic code and pipelines. Ability to integrate, optimize, and enhance multiple data sources for performance, governance, and reproducibility.

Ability to apply advanced statistical, predictive, and diagnostic methods to uncover drivers of quality, efficiency, and financial outcomes. Deep understanding of managed care operations, such as capitation models, provider networks, utilization management, and quality incentive programs. Ability to translate multi-domain data into actionable insights that directly inform strategic and operational decisions. Ability to conduct root-cause analyses, scenario modeling, and complex problem solving with minimal guidance.

Ability to operate with high autonomy, independently defining priorities and managing complex, ambiguous analytic projects. Ability to communicate complex analytic findings effectively to senior leadership, executives, and external stakeholders. Ability to translate insights into actionable recommendations and strategic narratives that influence enterprise decision making. Ability to mentor and guide other analysts, promoting analytic best practices across teams. Ability to drive continuous improvement of analytic tools, data structures, and reporting ecosystems, proactively identifying opportunities to enhance organizational performance. 

Preferred:

Proficient with Process Improvement Methodology including defining and documenting workflow. Knowledge of program and project level planning, mobilization and management.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Domain Specific Experience and Skills:

Domain Focus: Member Experience Analytics

Required: Experience analyzing call center operations, enrollment services, and appeals & grievances. Experience translating data into actionable insights to improve member experience and member engagement operations. Knowledge of Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys or other member satisfaction measurement tools. Ability to assess member touchpoints, satisfaction metrics, and operational KPIs.

Domain Focus: Population Health Analytics

Required: Experience analyzing community supports, care management, health education, Managed Long Term Support Services (MLTSS), and intervention programs. Experience translating data into actionable insights to guide interventions, resource allocation, program improvements, and new ideas for member programs based on population needs. Knowledge of population health management frameworks and social determinants of health.  Ability to evaluate population level outcomes and operational performance metrics.

Preferred: Experience understanding and responding to ongoing California Department of Health Care Services (DHCS) requirements for various programs, such as CalAIM.
 

Physical Requirements

Additional Information

Domain Specific Experience and Skills:
Domain Focus: Quality Improvement Analytics

Required: Experience analyzing Healthcare Effectiveness Data and Information Set (HEDIS), Stars, and other quality measurement programs across both medical and pharmacy domains. Experience translating data into actionable insights to inform interventions, compliance, and performance improvement strategies. Knowledge of quality measurement frameworks, regulatory requirements, and reporting standards.

Preferred:  Experience supporting quality reporting requirements and initiatives for regulatory or accreditation programs (e.g., CMS, DHCS). Experience supporting provider focused incentive program analytics. Ability to evaluate performance metrics, trends, and gaps to support quality improvement initiatives.

Preferred Certification: Certified Professional in Healthcare Quality (CPHQ)
Domain Focus: Access to Care Analytics

Required: Experience analyzing appointment timeliness, access, and provider availability. Experience translating data into actionable insights to improve access, reduce barriers, and optimize provider scheduling. Experience supporting initiatives to improve network adequacy and member access, including operational interventions and performance monitoring. Knowledge of access measurement frameworks and regulatory requirements. Ability to evaluate member access metrics, network capacity, and operational performance.
Domain Focus: Enterprise Support Analytics

Required: Experience supporting enterprise level KPI maintenance, cross-domain dashboards, and measure ROI analyses. Experience translating data into actionable insights for strategic investments, operational decisions, and organizational performance monitoring. Knowledge of analytics frameworks, governance standards, and enterprise reporting processes. Ability to develop analytic tools and dashboards that consolidate insights across multiple domains.

Preferred:  Experience supporting talent development analytics or enterprise-wide strategic initiative evaluation.