Quality Specialist (MD Medicaid) | CareFirst BlueCross BlueShield


Resp & Qualifications


CareFirst, Inc., and its affiliated companies, generally referred to as CareFirst BlueCross BlueShield (CareFirst), is the Mid-Atlantic region’s largest private sector health insurer, serving the healthcare needs of 3.5 million members in Maryland, the District of Columbia, and portions of northern Virginia. The Company offers a comprehensive portfolio of products and services to individuals and groups, as well as state and federal government sponsored plans. With a market share almost three times that of the closest competitor, the company commands 45 percent penetration across the region.

In July 2018, Brian D. Pieninck assumed the role of President and CEO after serving as the company’s COO of Strategic Business Units and IT Division. Under his leadership, the organization completed an extensive review of its operations and clinical programs, resulting in an expansive 3-year strategy to grow and diversify the company’s core business. Along with a 5-year vision to drive the transformation of the healthcare experience across the continuum of its members, partners, and communities, the company has placed a renewed and intentional focus on fostering a mission-based culture, which drives every decision the company makes. The organization employs over 5,600 full-time employees in Maryland, Northern Virginia, the District of Columbia, and West Virginia. CareFirst has earned multiple workplace awards recognizing its leadership in diversity and inclusion, wellness engagement, and creation of a supportive and equitable work environment for all employees.

At CareFirst, you are part of an inspired, collaborative team that is building the healthcare experience we want for our families and our future. Every day, we make a meaningful difference in the communities where we live and work.

We practice empathy, seek to understand, invest in inclusion, demand equity and nurture belonging every day for our employees and the communities we serve. We rely on the rich diversity of our employees’ experiences and backgrounds to achieve our mission. Every year we host a Week of Equity and Action where we deepen our investment and commitment to diversity, equity, and inclusion. During this week thousands of employees engage in workshops and volunteerism with the goal of bettering themselves and our community.

  • Women make up around 70% of CareFirst’s employee population, and over 50% identify as BIPOC (Black, Indigenous, and people of color).
  • We have 9 resource groups that connect employees over shared identities (LGBTQ, veteran status, race, etc.) and passions (climate change, healthy living, leadership development).
  • Employees are encouraged to give back and volunteer in their communities with their civic engagement hours.

As a not-for-profit, CareFirst regularly ranks among the most philanthropic organizations with $65 million invested in the community in 2020 to improve overall health, and increase the accessibility, affordability, safety, and quality of healthcare throughout its market area. The company’s employees consistently add to this impact by devoting thousands of volunteer hours to numerous community organizations and social causes. The company’s continued efforts to reinvest in community health care programs has repeatedly earned CareFirst regional accolades as a leading corporate philanthropist, including the No. 2 and No. 7 spots on the Baltimore Business Journal and Washington Business Journal’s 2019 list of top corporate givers, respectively.


Utilizing the population health frameworks provided by NCQA Accreditation, HEDIS and CMS, this position is responsible for delivering culturally appropriate health promotion information to members that helps increase their access & reduce their barriers to preventive care resulting in industry-leading outcomes at a population level. Uses expertise in HEDIS and other technical quality measures and advanced member engagement techniques to ensure improved population health and accreditation results.

Essential Functions

  • Conducts member and provider outreach designed to close member gaps in care, documenting such efforts in a manner that allows collaboration with other team members and other member-facing care delivery staff.
  • Analyzes quality reports and claims data to assess up-to-the-minute member compliance status to a wide variety of quality measures, utilizing this information to improve compliance and member health outcomes.
  • Collaborates with a variety of in-home & community-based providers to locate non-compliant members, managing member referrals to those providers for a variety of gap-closing quality campaigns. Maintains access to provider reporting of gap-closure outcomes and facilitates the transmission of such information as supplemental data where allowed.
  • Maintains ongoing subject matter expertise in population health, measurement science, accreditation, and quality improvement. Utilizes the framework of NCQA Accreditation, HEDIS & CMS quality standards to accomplish and document the work products.


Education Level: Bachelor’s Degree in population health, public health, healthcare administration, business administration, health policy, economics, statistics, mathematics, data science, or a related field OR in lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Experience: 3 years professional experience in a business environment (public health, health insurance, management consulting fields preferred); evidence of progressing levels of responsibility.

Preferred Qualifications

  • Previous experience in member and provider engagement to influence behavior change and improved health outcomes.
  • Certification in Quality or Process Improvement Methods.
  • Direct experience with accreditation, HEDIS, CAHPS and other quality related activities a healthcare related environment and/or payor organization.
  • Data analytics experience working with large data sets to answer clinical, operational, or business questions; prior experience with healthcare data expected.

Knowledge, Skills And Abilities (KSAs)

  • Ability to engage health care consumer and/or health care providers in outcomes driven assessment, planning and execution of improvement activities.
  • Expertise in qualitative and quantitative data analyses and presentations.
  • End-to-end experience designing, developing, and implementing innovative strategies to improve population health.
  • Ability to conduct advanced analytics using SQL, Python, R, or similar.
  • Fluent in the use of Microsoft tools including Excel, Word, Power Point and Outlook.
  • Knowledge of healthcare claims, survey, clinical, and health data.
  • Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.


Department: MD Medicaid -QUALITY

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

Physical Demands

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship


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