Clinical Quality & Coding Improvement Analyst

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

Job summary

Highmark Health seeks a dedicated professional to drive process improvement across compliance, coding, and quality initiatives. You will analyze data, review medical records, and educate providers and staff on optimal documentation, ICD-10-CM coding, and STARs improvements.

You will coordinate credentialing, audits, and regulatory updates while supporting accreditation goals. A healthcare background with HEDIS/HCC experience and strong communication skills is essential for success.

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.

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.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical thinking

Problem-solving

Medical administrator liaison

Education

RN or LPN license

Bachelor's degree in healthcare

Job description

Highmark Health seeks a dedicated professional to drive process improvement across compliance, coding, and quality initiatives. You will analyze data, review medical records, and educate providers and staff on optimal documentation, ICD-10-CM coding, and STARs improvements.

You will coordinate credentialing, audits, and regulatory updates while supporting accreditation goals. A healthcare background with HEDIS/HCC experience and strong communication skills is essential for success.