Clinical Quality & Compliance Analyst

Highmark Health; Virginia Beach (VA); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a Healthcare Compliance Analyst to collaborate with compliance, process improvement, medical record review, and coding teams across all product lines. You will support documentation improvement, ICD-10-CM coding accuracy, and provider education to enhance STARs and value-based care metrics.

The role involves audits, site visits, credentialing coordination, and potential investigations, with office-based work and periodic travel up to 25%.

Qualifications

• Required: Current state RN or LPN licensure 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
• Experience: 3 years of nursing or healthcare-related field
• Preferred: Medicaid/Medicare experience, Managed Care Organization experience

Responsibilities

• Develop and manage process improvement initiatives from the Organization for member and providers to include data analysis, process analysis, report generation, medical record documentation, and HCC Coding
• Conduct data collection and analysis from office site or medical record reviews to improve care, documentation and coding for members; assign ICD10-CM codes for chronic conditions
• Monitor regulatory/accrediting body requirements and adjust the compliance plan to CMS Coding Guidelines
• Conduct retrospective, concurrent, and prospective audits; identify gaps and communicate results
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding
• Perform re-audits as needed
• Other duties as assigned or requested

Skills

Quality improvement

Data analysis

Regulatory compliance

HEDIS awareness

Communication

Education

RN or LPN license or healthcare Bachelor's

6 years healthcare QA/HEDIS experience

3 years nursing/healthcare experience

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a Healthcare Compliance Analyst to collaborate with compliance, process improvement, medical record review, and coding teams across all product lines. You will support documentation improvement, ICD-10-CM coding accuracy, and provider education to enhance STARs and value-based care metrics.

The role involves audits, site visits, credentialing coordination, and potential investigations, with office-based work and periodic travel up to 25%.