Clinical Quality & Coding Improvement Analyst

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

Job summary

Highmark Health is seeking an experienced quality improvement professional to lead process improvement activities across compliance, coding, and medical record review for all product lines.

You will educate providers on documentation standards and coding guidelines, coordinate audits, and support credentialing and accreditation efforts. The role emphasizes data analysis, performance improvement, and collaboration with medical leadership.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-related field
• 6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor's degree
• Current state RN or LPN licensure OR multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), OR CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• 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.
• Conduct continuing education to providers on STARS, HEDIS, and HCC Coding.
• Conduct re-audits as needed.
• Other duties as assigned or requested.

Education

RN/LPN license or healthcare degree

Tools

Microsoft Office

Data analysis

Job description

Highmark Health is seeking an experienced quality improvement professional to lead process improvement activities across compliance, coding, and medical record review for all product lines.

You will educate providers on documentation standards and coding guidelines, coordinate audits, and support credentialing and accreditation efforts. The role emphasizes data analysis, performance improvement, and collaboration with medical leadership.