Clinical Quality & Coding Analyst – HEDIS/Stars Focus

Highmark Health; Providence (RI); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a compliance and quality improvement professional to drive process improvements across departments focused on documentation, ICD-10-CM coding, and overall member/provider satisfaction.

The role includes education for providers on STARS, HEDIS, and HCC coding, audits, credentialing coordination, and ongoing monitoring of CMS and NCQA standards to ensure timely improvements.

Qualifications

• RN or LPN license or healthcare-related bachelor's degree.
• 6 years of HEDIS/Quality abstraction, HCC coding, or healthcare-related field in lieu of bachelor’s degree.
• Experience: 3 years of nursing or healthcare-related field.
• Preferred: Medicaid/Medicare experience.
• Preferred: experience with Managed Care Organizations.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct site visits and medical record reviews to improve care, documentation, and coding for members; properly assign ICD-10-CM codes.
• Coordinate credentialing, re-credentialing, audits, and quality programs to improve STARs and value-based care; support accreditation.
• Conduct continuing education to providers on STARS, HEDIS, and HCC coding; perform re-audits as needed.
• Monitor regulatory/accrediting changes and adjust the compliance plan accordingly.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical skills

Problem solving

Education

RN or LPN license or healthcare degree

eNLC multi-state license / other certs

Job description

Highmark Inc. is seeking a compliance and quality improvement professional to drive process improvements across departments focused on documentation, ICD-10-CM coding, and overall member/provider satisfaction.

The role includes education for providers on STARS, HEDIS, and HCC coding, audits, credentialing coordination, and ongoing monitoring of CMS and NCQA standards to ensure timely improvements.