Clinical Quality & Compliance Analyst

Highmark Health; Charleston (WV); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. seeks a professional to advance quality improvement, coding accuracy, and regulatory compliance across all product lines. You will educate providers on documentation, conduct audits, and support credentialing and accreditation efforts.

The role emphasizes HEDIS, STARS, and CMS guidelines, requiring nursing licensure and applicable certifications. Travel may be required; office-based position with collaboration across departments.

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 experience
• 1 year of project management experience
• Medicaid/Medicare experience
• Preferred experience with Managed Care Organizations
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• Current state or multi-state licensure via eNLC is preferred

Responsibilities

• Develop and manage process improvement initiatives for members and providers with data analysis, reporting, and documentation.
• Analyze office site and medical records to improve care, coding, STARS, and accreditation.
• Monitor regulatory changes and update the compliance plan per CMS guidelines.
• Conduct retrospective, concurrent, and annual audits and communicate gaps.
• Provide continuing education to providers on STARS, HEDIS, and HCC coding.
• Perform re-audits as needed.
• Other duties as assigned or requested.

Skills

Quality improvement

HCC Coding

Medical record documentation

CMS/NCQA standards

Data analysis

Auditing

Project management

HIPAA compliance

Excel

Education

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

Tools

Microsoft Office

Job description

Highmark Inc. seeks a professional to advance quality improvement, coding accuracy, and regulatory compliance across all product lines. You will educate providers on documentation, conduct audits, and support credentialing and accreditation efforts.

The role emphasizes HEDIS, STARS, and CMS guidelines, requiring nursing licensure and applicable certifications. Travel may be required; office-based position with collaboration across departments.