Clinical Quality & Compliance Analyst

Highmark Health; South Dakota Park (SD); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health in the United States is seeking a quality and compliance professional to oversee process improvement, medical record review, and coding across product lines. The role focuses on documenting care in ICD-10-CM coding and aligning with CMS and NCQA standards, while educating providers and office staff.

You will lead audits, staff education, and coordination of credentialing activities, with a focus on STARS and value-based care, and you may travel to multiple sites as needed.

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/medical coding, or healthcare related field in lieu of bachelor's degree
• Preferred: ~ None

Responsibilities

• Develop and manage process improvement initiatives for members and providers with detailed data analysis, process analysis, report generation, and medical record documentation.
• Conduct, collect and analyze information from office site and/or medical record reviews to improve care, documentation and coding for members, to assign ICD10-CM codes, and coordinate with revenue programs and quality improvement for STARs and value-based care.
• Monitor regulatory requirements and adjust the compliance plan to CMS Coding Guidelines; conduct audits, provide education on STARS and HEDIS, and perform re-audits as needed.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Data analysis

Education

RN or LPN license or Bachelor's degree in Healthcare

eNLC/CPC/CRC/RHIA/RHIT/CCS certification or must obtain within 4 months

Job description

Highmark Health in the United States is seeking a quality and compliance professional to oversee process improvement, medical record review, and coding across product lines. The role focuses on documenting care in ICD-10-CM coding and aligning with CMS and NCQA standards, while educating providers and office staff.

You will lead audits, staff education, and coordination of credentialing activities, with a focus on STARS and value-based care, and you may travel to multiple sites as needed.