Clinical Quality & Coding Analyst (HEDIS/HCC)

Highmark Health; Washington (District of Columbia); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a healthcare quality professional to drive process improvements, analyze data, and ensure accurate medical record documentation and coding. The role includes audits, education for providers on STARS, HEDIS, and HCC coding, and coordination of credentialing activities as needed.

The candidate should have an RN/LPN license or healthcare degree and at least 3 years of nursing or related experience. Strong communication and data skills are essential.

Qualifications

• Current state RN or LPN license or Bachelor’s degree in a Healthcare-related field.
• 3 years of nursing or healthcare-related experience required.
• 6 years of HEDIS/Quality abstraction or related healthcare experience can substitute for degree.
• Preferred experience with PMO/Managed Care experience is noted.

Responsibilities

• Develop and manage process improvement initiatives with data analysis and reporting.
• Conduct medical record reviews to improve documentation and coding for members.
• Monitor regulatory/accrediting requirements and update the compliance plan.
• Perform audits (retrospective, concurrent, prospective) and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.
• Coordinate site visits and other reviews as requested.

Skills

TQM knowledge

Statistics understanding

Verbal and written communication

Communication with medical admins

Computer literacy, MS Office

Analytical problem-solving

Education

RN/LPN license or healthcare degree

Job description

Highmark Inc. is seeking a healthcare quality professional to drive process improvements, analyze data, and ensure accurate medical record documentation and coding. The role includes audits, education for providers on STARS, HEDIS, and HCC coding, and coordination of credentialing activities as needed.

The candidate should have an RN/LPN license or healthcare degree and at least 3 years of nursing or related experience. Strong communication and data skills are essential.