Clinical Quality & Compliance Analyst

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

Job summary

Highmark Health in Illinois seeks a clinical quality professional to drive compliance, process improvement, medical record review, and HCC coding initiatives across product lines. You will educate providers and staff on documentation standards, CMS/NCQA guidelines, and STARS criteria while coordinating audits and credentialing activities.

You will lead retrospective and concurrent reviews, analyze data, identify gaps, and implement action plans to improve care quality and coding accuracy in a

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
• 1 year of project management experience
• Medicaid/Medicare experience
• Managed Care Organizations experience

Responsibilities

• Develop and manage process improvement initiatives across departments via data analysis and reporting.
• Conduct medical record reviews and code chronic conditions (ICD-10-CM) with HCC focus.
• Educate providers and office staff on documentation standards and CMS/NCQA guidelines.
• Perform audits and coordinate credentialing and STARS improvement activities.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Data analysis

MS Office

Education

RN/LPN license or healthcare BA

CPC/CRC/RHIA/RHIT/CCS

Tools

Office suite tools

Job description

Highmark Health in Illinois seeks a clinical quality professional to drive compliance, process improvement, medical record review, and HCC coding initiatives across product lines. You will educate providers and staff on documentation standards, CMS/NCQA guidelines, and STARS criteria while coordinating audits and credentialing activities.

You will lead retrospective and concurrent reviews, analyze data, identify gaps, and implement action plans to improve care quality and coding accuracy in a