Clinical Quality & Compliance Analyst

Highmark Health; Maryland City (MD); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a Quality Improvement role focused on process improvement and accurate ICD-10-CM coding across product lines. The role entails collaboration with compliance, coding, and accreditation teams to support STARs and HEDIS initiatives.

The candidate will review medical records, educate providers on documentation standards, and coordinate audits to ensure timely and accurate coding. Strong knowledge of CMS/CNHQA guidelines is essential.

Qualifications

• RN or LPN license or healthcare bachelor's degree.
• 6 years of experience with HEDIS/Quality abstraction, HCC coding, or healthcare field in lieu of bachelor’s degree.
• 3 years of nursing or healthcare-related field.
• 1 year of project management experience (preferred).
• Medicaid/Medicare experience (preferred).
• CCP/CRC/RHIA/RHIT/CCS certification within 4 months of hire (required).
• RN with active compact license (preferred).

Responsibilities

• Develop and manage process improvement initiatives with data analysis, process analysis, report generation, medical record documentation, and HCC coding.
• Conduct audits and reviews to improve care, documentation, and coding for members.
• Monitor regulatory changes and adjust the compliance plan per CMS guidelines.
• Perform retrospective, concurrent, and prospective audits; provide continuing education on STARS, HEDIS, and HCC Coding.
• Other duties as assigned.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical skills

Problem solving

Education

RN/LPN license or healthcare bachelor

Tools

Excel

Word

Access

PowerPoint

Job description

Highmark Inc. is seeking a Quality Improvement role focused on process improvement and accurate ICD-10-CM coding across product lines. The role entails collaboration with compliance, coding, and accreditation teams to support STARs and HEDIS initiatives.

The candidate will review medical records, educate providers on documentation standards, and coordinate audits to ensure timely and accurate coding. Strong knowledge of CMS/CNHQA guidelines is essential.