Clinical Quality & Compliance Analyst

Highmark Health; Santa Fe (NM); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. seeks a Quality Improvement professional to collaborate with compliance, process improvement, medical record review, and coding across product lines.

You will implement process improvements to enhance quality of care and documentation for ICD-10-CM coding and STARS initiatives. The role acts as a resource and educator on provider documentation, CMS/NCQA standards, and continuous quality improvement.

Qualifications

• Current 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
• Medicaid/Medicare experience
• Preferred experience with Managed Care Organizations

Responsibilities

• 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 improve care, documentation and coding for members and to properly assign ICD10-CM codes.
• Monitor regulatory/accrediting requirements and adjust the compliance plan to follow CMS Coding Guidelines.
• Conduct audits (retrospective, concurrent, prospective) and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC coding.
• Coordinate re-audits and other reviews as needed.

Skills

Verbal communication

Written communication

Data analysis

Process improvement

HCC Coding knowledge

Training delivery

Problem solving

Education

RN or LPN license or healthcare-related Bachelor's

6 years HEDIS/Quality abstraction or healthcare experience in lieu of degree

3 years nursing/healthcare experience

Medicaid/Medicare experience

Managed Care Organizations experience preferred

Job description

Highmark Inc. seeks a Quality Improvement professional to collaborate with compliance, process improvement, medical record review, and coding across product lines.

You will implement process improvements to enhance quality of care and documentation for ICD-10-CM coding and STARS initiatives. The role acts as a resource and educator on provider documentation, CMS/NCQA standards, and continuous quality improvement.