Clinical Quality & Compliance Analyst

Highmark Health; Clifton (TX); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health seeks a healthcare quality professional to collaborate with compliance, process improvement, medical record review, and coding across product lines. You will drive improvements for quality care and accurate ICD-10-CM coding.

You will educate providers and staff on documentation, CMS/NCQA standards, HCC coding, and STARS initiatives; perform audits and site visits to improve performance.

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.
• Strong understanding of CMS/HEDIS/STARS principles is preferred.

Responsibilities

• Develop and manage process improvement initiatives from the Organization for member and providers to include data analysis, process analysis, and report generation.
• Conduct medical record reviews and coding to improve documentation and ICD-10-CM coding accuracy.
• Educate providers and office staff on CMS/HIPAA standards and quality improvement methods.
• Perform audits (retrospective, concurrent, prospective) and coordinate credentialing activities as requested.
• Support compliance with regulatory and accrediting body requirements (CMS, NCQA).

Skills

TQM concepts

Statistics understanding

Verbal communication

Written communication

Microsoft Office

Data interpretation

Education

RN or LPN license

Bachelor’s in healthcare field

Tools

CPC

CRC

RHIA

RHIT

CCS

Job description

Highmark Health seeks a healthcare quality professional to collaborate with compliance, process improvement, medical record review, and coding across product lines. You will drive improvements for quality care and accurate ICD-10-CM coding.

You will educate providers and staff on documentation, CMS/NCQA standards, HCC coding, and STARS initiatives; perform audits and site visits to improve performance.