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.

Responsibilities

In this role, you will:

• Use deep understanding of underlying business requirements to conceptualize and develop analytical systems that meet important business needs
• Design and develop these systems so that they can be used by lower-level analysts thereby promoting company-wide efficiencies
• Lead the architectural transition of legacy, on-premise analytic workflows and data pipelines into modern, cloud-native environments, utilizing Databricks, Snowflake, and other enterprise-governed cloud tools to ensure scalable, automated business logic.
• Coordinate activities with other internal departments to maximize overall efficiency and resolve conflicts
• Communicate project status, progress, and outcomes to executive management
• Fulfill a leadership role in the critical review and ongoing development of data management and analytical systems for strategically important enterprise-wide analysis and reporting
• 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

Qualifications

Your 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

Hybrid

This 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 Us

About 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!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other