Clinical Quality & Compliance Analyst

Highmark Health; Nashville (TN); Remoto; USD 63.000 - 97.000; Tempo pieno

Descrizione del lavoro

Highmark Inc. in Nashville, TN seeks a healthcare quality and compliance professional to drive process improvements, coding accuracy, and provider documentation across product lines; you will educate teams on CMS and NCQA standards and lead medical record reviews and audits.

The role coordinates with credentialing, revenue and quality programs, performs audits, and supports STARS and value-based care initiatives, while ensuring HIPAA compliance and continuous improvement.

Competenze

• 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
• Required: 3 years of nursing or healthcare-related field
• Required-Current State RN or LPN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), ORCPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• RN with an active compact license (preferred)

Mansioni

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

Conoscenze

Total Quality Management (TQM)

Statistics

Verbal communication

Written communication

Problem identification & resolution

Microsoft Office (Word, Excel, Access,

Formazione

RN/LPN license or Bachelor's degree in healthcare field

HEDIS/Quality abstraction or healthcare field in lieu of Bachelor's degree

3 years nursing/healthcare experience

eNLC/multi-state licensure or CCS/RHIA/RHIT certification or within 4 months of hire

RN with active compact license (preferred)

Strumenti

Microsoft Office

Descrizione del lavoro

Highmark Inc. in Nashville, TN seeks a healthcare quality and compliance professional to drive process improvements, coding accuracy, and provider documentation across product lines; you will educate teams on CMS and NCQA standards and lead medical record reviews and audits.

The role coordinates with credentialing, revenue and quality programs, performs audits, and supports STARS and value-based care initiatives, while ensuring HIPAA compliance and continuous improvement.