Clinical Quality Management Analyst - RN (Remote)

Highmark Health; Dover; Remote; GBP 47,000 - 73,000; Full time

Job summary

Highmark Health seeks a qualified healthcare professional to lead process-improvement initiatives across departments focusing on compliant documentation and accurate ICD-10-CM coding. Responsibilities include audits, education of providers on STARS and HEDIS, and coordination with credentialing and quality programs to drive value-based care.

Required: RN/LPN license or Bachelor’s in healthcare, plus 3 years in healthcare; preferred PM experience and certification credentials such as CPC, CRC,

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-related field.
• Substitutions: 6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor's degree.

Responsibilities

• Develop and manage process improvement initiatives from the Organization for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and achieve and maintain accreditation.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan to follow CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective, semi-annual, and annual audits, identify gaps and communicate results. Conduct continuing education to providers on STARS, HEDIS, and HCC Coding. Conduct re-audits as needed
• Other duties as assigned or requested.

Education

Bachelor’s degree in healthcare

Tools

Microsoft Office

Job description

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job works with appropriate departments in the areas of compliance, process improvement, medical record review and coding, and member and provider satisfaction for all product lines. Recommends and implements process improvements related to the potential of quality medical care and service to members and to improve documentation of these services for appropriate ICD 10-CM coding. Serves as a resource and educator regarding provider and office staff medical record documentation, federal and state standards including CMS and NCQA standards and continuous quality improvement principles. Perform special studies per audits, conducting office site visits and medical records reviews, ensuring improvement in performance for various initiatives in a timely manner. May coordinate credentialing, re-credentialing, member complaint investigations, Medical Director site visit requests, facility site visit requests, activities to include other reviews, audits, accreditation activities as requested on behalf of the organization.

ESSENTIAL RESPONSIBILITIES

• Develop and manage process improvement initiatives from the Organization for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.

• Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and achieve and maintain accreditation.

• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan to follow CMS Coding Guidelines.

• Conduct retrospective, concurrent, and prospective, semi-annual, and annual audits, identify gaps and communicate results. Conduct continuing education to providers on STARS, HEDIS, and HCC Coding. Conduct re-audits as needed

• Other duties as assigned or requested.

EDUCATION

Required

• Current state RN or LPN license or Bachelor’s degree in a Healthcare-related field

Substitutions

• 6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor's degree

Preferred

• None

EXPERIENCE

Required

• 3 years of nursing or healthcare-related field

Preferred

• 1 year of project management experience
• Medicaid/Medicare experience
• Preferred experience with Managed Care Organizations

LICENSES OR CERTIFICATIONS

Required

• Current State RN or LPN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), OR
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire

Preferred

• RN with an active compact license

SKILLS

• An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements
• An understanding of statistics is also preferred to analyze various reports and validate study methodologies
• Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles. Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring, and problem resolution.
• Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
• Well-developed, analytical and problem-solving skills with the ability to understand and interpret clinical data

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Never

Disclaimer:

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$62,700.00

Pay Range Maximum:

$97,200.00

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice (https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib_458575_QLVK9_1769448333304228022_1769448333396/1769448333396.pdf)