Clinical Quality Analyst — Process & Coding Excellence

Highmark Health; Florida; Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a healthcare quality/compliance professional to drive process improvements across compliance, coding, and documentation with a focus on improving CMS and NCQA measures.

The role coordinates credentialing activities, supports audits and education for providers, and ensures timely delivery of quality initiatives across all product lines. Strong data analysis and communication skills are essential.

Qualifications

• Current state RN or LPN license or Bachelor’s degree in a Healthcare-related field.
• 6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor's degree.
• 3 years of nursing or healthcare-related field experience.
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, reporting, and proper documentation.
• Analyze information from site reviews to improve care, services, documentation, and coding for members.
• Monitor regulatory/accrediting requirements and adjust the compliance plan per CMS guidelines.
• Conduct audits (retrospective, concurrent, semi-annual, annual) and provide continuing education on STARS, HEDIS, and HCC Coding.

Skills

Quality improvement

Data analysis

Verbal communication

Written communication

Microsoft Office

Analytics

Education

RN or LPN license or healthcare-related Bachelor's

CPC/CRC/RHIA/RHIT/CCS certification or willingness to obtain

6 years healthcare quality/HEDIS coding experience in lieu of degree

Tools

Excel

Access

PowerPoint

Job description

Highmark Inc. is seeking a healthcare quality/compliance professional to drive process improvements across compliance, coding, and documentation with a focus on improving CMS and NCQA measures.

The role coordinates credentialing activities, supports audits and education for providers, and ensures timely delivery of quality initiatives across all product lines. Strong data analysis and communication skills are essential.