Clinical Quality & Compliance Analyst

Highmark Health; Accident (AR); À distance; USD 63 000 - 97 000; Plein temps

Résumé du poste

Highmark Inc. is seeking a quality and compliance professional to collaborate across departments on process improvements, medical record review, and accurate ICD-10-CM coding across all product lines.

The role focuses on education for providers, adherence to CMS/NHQ standards, and continuous quality improvement. It involves audits and site visits to enhance documentation and member/provider satisfaction.

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.
• 3 years of nursing or healthcare-related field required.
• CPC, CRC, RHIA, RHIT, or CCS certification or must obtain within 4 months after hire.

Responsabilités

• Develop and manage process improvement initiatives including data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct information and data collection from office site and/or medical record reviews to improve care, documentation, and coding for members; properly assign ICD-10-CM codes and coordinate with revenue programs, credentialing, and quality improvement programs.
• Monitor regulatory and accrediting requirements and adjust the compliance plan to CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective audits; identify gaps and communicate results; provide continuing education to providers on STARS, HEDIS, and HCC Coding; perform re-audits as needed.
• Other duties as assigned or requested.

Connaissances

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Data analysis

Formation

RN or LPN license or healthcare degree

Bachelor’s degree in healthcare field

Outils

Microsoft Excel

Description du poste

Highmark Inc. is seeking a quality and compliance professional to collaborate across departments on process improvements, medical record review, and accurate ICD-10-CM coding across all product lines.

The role focuses on education for providers, adherence to CMS/NHQ standards, and continuous quality improvement. It involves audits and site visits to enhance documentation and member/provider satisfaction.