Clinical Quality & Coding Analyst

Highmark Health; Boston (MA); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health seeks a quality improvement and coding professional to support multiple product lines, focusing on documentation, ICD-10-CM coding, and provider education. The role includes conducting audits, educational activities, and coordinating with credentialing and accreditation programs.

The ideal candidate will have RN/LPN or healthcare degree with relevant coding certification, experience in quality programs, and strong data analysis and CMS/NCQA knowledge.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a healthcare-related field.
• 6 years of HEDIS/Quality abstraction or HCC Coding experience in lieu of a 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 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.

Skills

TQM concepts

Statistics knowledge

Verbal communication

Written communication

Microsoft Office

Analytical/problem-solving

Education

RN/LPN license or Bachelor's in healthcare

Job description

Highmark Health seeks a quality improvement and coding professional to support multiple product lines, focusing on documentation, ICD-10-CM coding, and provider education. The role includes conducting audits, educational activities, and coordinating with credentialing and accreditation programs.

The ideal candidate will have RN/LPN or healthcare degree with relevant coding certification, experience in quality programs, and strong data analysis and CMS/NCQA knowledge.