Clinical Quality & Compliance Analyst

Highmark Health; Hartford (CT); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a Compliance/Quality Improvement professional to partner with departments across the organization. You will review medical records, ensure proper ICD-10-CM coding, and drive process improvements to elevate member and provider satisfaction.

You will educate providers on STARS, HEDIS and HCC coding while coordinating audits and credentialing activities to support accreditation efforts. This role involves travel up to 25% and requires healthcare experience.

Qualifications

• Current 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.
• Experience: 3 years nursing or healthcare-related field.
• PreferredNone

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 care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with 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

Computer literacy

Microsoft Office

Education

RN or LPN license or healthcare-related Bachelor's

3 years nursing/healthcare experience

Experience substituting 6 years in lieu of bachelor's

1 year project management experience

Medicaid/Medicare experience

Managed Care Organization experience

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a Compliance/Quality Improvement professional to partner with departments across the organization. You will review medical records, ensure proper ICD-10-CM coding, and drive process improvements to elevate member and provider satisfaction.

You will educate providers on STARS, HEDIS and HCC coding while coordinating audits and credentialing activities to support accreditation efforts. This role involves travel up to 25% and requires healthcare experience.