Clinical Quality & Compliance Analyst (Coding & Audits)

Highmark Health; Louisiana; Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health seeks a healthcare quality professional to drive process improvements and ensure accurate documentation for ICD-10-CM coding across product lines. You will collaborate with compliance, process improvement, medical record review, and accreditation activities to enhance care quality and provider/provider staff satisfaction.

The role requires RN/LPN licensure or a healthcare-related degree, with 3+ years in nursing or related field and familiarity with HEDIS/STARS metrics.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a healthcare-related field.
• Substitutions: 6 years of HEDIS/Quality abstraction or healthcare field in lieu of degree.
• Experience with HEDIS, HCC coding, and CMS/NCQA standards is preferred.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, reporting, and medical record documentation.
• Ensure proper ICD-10-CM coding for chronic conditions and coordinate with revenue programs and quality improvement.
• Conduct audits (retrospective, concurrent, annual) and communicate results to stakeholders.
• Educate providers on STARS, HEDIS, and HCC coding; perform re-audits as needed.
• Coordinate credentialing and credentialing-related activities and site visits.

Skills

TQM concepts and metrics

Statistics understanding

Verbal communication

Written communication

Proficiency with Microsoft Office

Problem-solving and analytics

Education

RN or LPN licensure OR Bachelor's in healthcare

6 years HEDIS/Quality abstraction or healthcare field (in lieu of degree)

Tools

Microsoft Office

Job description

Highmark Health seeks a healthcare quality professional to drive process improvements and ensure accurate documentation for ICD-10-CM coding across product lines. You will collaborate with compliance, process improvement, medical record review, and accreditation activities to enhance care quality and provider/provider staff satisfaction.

The role requires RN/LPN licensure or a healthcare-related degree, with 3+ years in nursing or related field and familiarity with HEDIS/STARS metrics.