Clinical Quality & Compliance Analyst

Highmark Health; New Mexico; À distance; USD 63 000 - 97 000; Plein temps

Résumé du poste

Highmark Inc. is seeking a Quality & Compliance professional to collaborate with multiple departments across product lines. The role focuses on improving documentation, ICD-10-CM coding accuracy, and STARS/HEDIS metrics through process improvements and training.

You will conduct audits, educator for staff, and support credentialing and review activities while ensuring adherence to CMS, NCQA, HIPAA, and privacy policies. Office-based with periodic site visits may be required.

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 required.

Responsabilités

• 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.

Connaissances

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical skills

Formation

RN or LPN license

Bachelor’s degree in healthcare-related field

Healthcare-related degree or higher

Outils

Microsoft Office

Description du poste

Highmark Inc. is seeking a Quality & Compliance professional to collaborate with multiple departments across product lines. The role focuses on improving documentation, ICD-10-CM coding accuracy, and STARS/HEDIS metrics through process improvements and training.

You will conduct audits, educator for staff, and support credentialing and review activities while ensuring adherence to CMS, NCQA, HIPAA, and privacy policies. Office-based with periodic site visits may be required.