Clinical Quality & Compliance Analyst – HEDIS, Coding

Highmark Health; Alaska; Teletrabalho; USD 63 000 - 97 000; Tempo integral

Resumo da oferta

Highmark Health is seeking a compliance and quality improvement professional to collaborate with departments on improving documentation, coding, and patient care across product lines. The role emphasizes education on CMS/NCQA standards, conducting audits, and driving continuous quality initiatives to enhance provider performance and member satisfaction.

The position requires healthcare-related education and licensure and offers opportunities to coordinate credentialing and extensive data-driven

Qualificações

• Current RN or LPN license or healthcare-related bachelor's degree.
• 3 years of nursing or healthcare-related experience.
• CPC, CRC, RHIA, RHIT, or CCS certification or must obtain within 4 months of hire.
• 6 years of experience with HEDIS/Quality abstraction, HCC coding, or healthcare field in lieu of bachelor's.

Responsabilidades

• Develop and manage process improvements with data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Analyze information from office/site reviews to improve care, documentation, and coding for members; align with revenue, credentialing and quality programs to improve STARS, value-based care and accreditation.
• Monitor regulatory/accrediting body changes and adjust the compliance plan to CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective audits; perform education on STARS, HEDIS, and HCC coding; perform re-audits as needed.
• Coordinate credentialing, re-credentialing, member complaint investigations, and related reviews as requested.

Conhecimentos

TQM concepts

Statistics

Communication skills

MS Office

Analytical thinking

Problem-solving

Formação académica

RN or LPN license or healthcare-related bachelor's

CPC/CRC/RHIA/RHIT/CCS Certification

eNLC multi-state licensure

6 years HEDIS/Quality abstraction or coding experience (in lieu of bachelor)

Descrição da oferta de emprego

Highmark Health is seeking a compliance and quality improvement professional to collaborate with departments on improving documentation, coding, and patient care across product lines. The role emphasizes education on CMS/NCQA standards, conducting audits, and driving continuous quality initiatives to enhance provider performance and member satisfaction.

The position requires healthcare-related education and licensure and offers opportunities to coordinate credentialing and extensive data-driven