Clinical Quality & Coding Improvement Analyst

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

Job summary

Highmark Health in California is seeking a healthcare quality professional to support compliance, process improvement, and coding across product lines. You will review medical records, assign ICD-10-CM codes including HCCs, and help improve documentation to meet CMS, NCQA, and STARS requirements.

The role involves data analysis, audits, site visits, and collaboration with multiple departments. You will educate providers and office staff on documentation standards and quality improvement

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-related field.
• Substitutions: ~6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor’s degree.
• Requires ~3 years of nursing or healthcare-related field experience.
• Preferred: Medicaid/Medicare experience and Managed Care Organization experience.

Responsibilities

• Lead process improvement initiatives with data analysis, analysis, report generation, and coding.
• Perform medical record reviews to assign ICD-10-CM codes and HCC coding; improve documentation.
• Educate providers and staff on STARS, HEDIS, and HCC coding.
• Conduct audits and re-audits; communicate gaps and results.
• Coordinate credentialing and re-credentialing activities as requested.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Medical data analysis

MS Office

Clinical data interpretation

Education

RN or LPN license

Bachelor’s degree in healthcare

Tools

Microsoft Office

Job description

Highmark Health in California is seeking a healthcare quality professional to support compliance, process improvement, and coding across product lines. You will review medical records, assign ICD-10-CM codes including HCCs, and help improve documentation to meet CMS, NCQA, and STARS requirements.

The role involves data analysis, audits, site visits, and collaboration with multiple departments. You will educate providers and office staff on documentation standards and quality improvement