Clinical Quality & Compliance Analyst

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

Job summary

Highmark Health is seeking a skilled professional to collaborate with compliance, process improvement, medical record review, coding, and payer relations across product lines. You will recommend and implement improvements to support high-quality care and accurate ICD-10-CM coding, serving as a resource for providers and staff.

You will lead audits, education on STARS, HEDIS, and HCC Coding, and coordinate credentialing activities.

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, or healthcare related field in lieu of bachelor's degree

Responsibilities

• Develop and manage process improvement initiatives with detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct office site visits and medical record reviews to improve documentation and coding for members and monitoring STARS/HEDIS/HCC outcomes.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding; conduct re-audits as needed.
• Coordinate credentialing, re-credentialing and related audits and compliance activities as requested

Skills

TQM concepts

Statistics knowledge

Verbal communication

Written communication

MS Office familiarity

Data analysis

Problem solving

Education

RN or LPN license or healthcare-related Bachelor's

Job description

Highmark Health is seeking a skilled professional to collaborate with compliance, process improvement, medical record review, coding, and payer relations across product lines. You will recommend and implement improvements to support high-quality care and accurate ICD-10-CM coding, serving as a resource for providers and staff.

You will lead audits, education on STARS, HEDIS, and HCC Coding, and coordinate credentialing activities.