Clinical Quality & Coding Analyst RN

Highmark Health; Augusta (ME); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a healthcare quality and coding professional to support compliance, process improvement, and medical record review across product lines.

The role emphasizes accurate ICD-10-CM coding, documentation, and ongoing provider education to enhance STARs and value-based care. The position requires RN/LPN licensure or healthcare-related bachelor’s degree, 3 years in healthcare, and relevant certifications within 4 months of hire.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-related field.
• 3 years of nursing or healthcare-related field
• Certification CPC, CRC, RHIA, RHIT, or CCS within 4 months of 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 audits and reviews to improve documentation and coding for STARS, value-based care, and accreditation.
• Monitor regulatory/accrediting body requirements and adjust the compliance plan to CMS Coding Guidelines.
• Perform various audits (retrospective, concurrent, prospective) and conduct continuing education for providers on STARS, HEDIS, and HCC Coding.
• Other duties as assigned or requested.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical skills

Education

RN or LPN license

Bachelor's degree in healthcare-related field

CPC/CRC/RHIA/RHIT/CCS certification

eNLC multi-state licensure

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a healthcare quality and coding professional to support compliance, process improvement, and medical record review across product lines.

The role emphasizes accurate ICD-10-CM coding, documentation, and ongoing provider education to enhance STARs and value-based care. The position requires RN/LPN licensure or healthcare-related bachelor’s degree, 3 years in healthcare, and relevant certifications within 4 months of hire.