Clinical Quality & Coding Improvement Analyst

Highmark Health; Lake Michigan Beach (MI); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health is seeking a quality improvement professional to collaborate with compliance, process improvement, medical record review and coding teams. You will drive initiatives to improve documentation, ensure CMS and NCQA standards, and support STARS and value-based care through data analysis and audits.

This role requires in-depth knowledge of HEDIS/HCC coding, strong communication, and the ability to educate providers and office staff on documentation best practices.

Qualifications

• State RN or LPN license or healthcare-related bachelor's degree.
• 6 years of experience with HEDIS/Quality abstraction or HCC coding or healthcare related field in lieu of bachelor's degree.
• 3 years of nursing or healthcare-related field
• RN with an active compact license (preferred)

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, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and achieve and maintain accreditation.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan to follow CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective, semi-annual, and annual audits, identify gaps and communicate results.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical skills

Problem solving

Regulatory knowledge

Education

RN or LPN license or healthcare-related bachelor's degree

Tools

Microsoft Office Suite

EMR systems knowledge

Job description

Highmark Health is seeking a quality improvement professional to collaborate with compliance, process improvement, medical record review and coding teams. You will drive initiatives to improve documentation, ensure CMS and NCQA standards, and support STARS and value-based care through data analysis and audits.

This role requires in-depth knowledge of HEDIS/HCC coding, strong communication, and the ability to educate providers and office staff on documentation best practices.