Clinical Quality & Coding Improvement Analyst

Highmark Health; Clayton (NC); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health is seeking a qualified professional to lead process improvement efforts across compliance, coding and quality programs. You will conduct medical record reviews, analyze data, and ensure accurate ICD-10-CM coding to support STARS and value-based care initiatives.

You will educate provider offices on documentation standards, coordinate credentialing activities, and perform audits as needed to drive performance and maintain regulatory compliance.

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
• Required: ~3 years of nursing or healthcare-related field
• Preferred: ~1 year of project management experience
• Preferred: Medicaid/Medicare experience and Managed Care Organization experience

Responsibilities

• Develop and manage process improvement initiatives for members and providers with 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 care, documentation and coding for members, ensuring proper ICD-10-CM coding.
• Coordinate with revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and accreditation.
• Conduct continuing education to providers on STARS, HEDIS, and HCC Coding.
• Perform audits and re-audits as needed; other duties as assigned.

Skills

TQM concepts

Statistics knowledge

Verbal communication

Written communication

MS Office

Analytical skills

Education

RN or LPN license or Bachelor's degree in healthcare

Tools

Microsoft Office

Job description

Highmark Health is seeking a qualified professional to lead process improvement efforts across compliance, coding and quality programs. You will conduct medical record reviews, analyze data, and ensure accurate ICD-10-CM coding to support STARS and value-based care initiatives.

You will educate provider offices on documentation standards, coordinate credentialing activities, and perform audits as needed to drive performance and maintain regulatory compliance.