Clinical Quality & Compliance Analyst (HEDIS/Coding)

Highmark Health; Guin (AL); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health in the United States seeks a healthcare quality professional to lead process improvement, documentation, and coding initiatives across product lines. You will work with compliance and medical record departments to enhance care quality and STAR ratings.

The role requires an RN/LPN license or equivalent, a healthcare degree, and coding certifications or the ability to obtain them within four months. Expect audits, training, and cross-functional collaboration.

Qualifications

• 3+ years of nursing or healthcare-related field experience.
• RN or LPN license or multi-state licensure via eNLC.
• Bachelor's degree in a healthcare-related field required.
• CPC, CRC, RHIA, RHIT, or CCS certification preferred or must obtain within 4 months.

Responsibilities

• Develop and manage process improvement initiatives for members and providers, including data analysis and reporting.
• Analyze office site and medical records to improve documentation and coding for accurate ICD-10-CM coding.
• Monitor regulatory/accrediting requirements and update the compliance plan accordingly.
• Conduct retrospective, concurrent, and prospective audits and provide staff education on STARS, HEDIS, and HCC Coding.
• Coordinate credentialing, re-credentialing, and related reviews as requested.

Skills

TQM concepts

Data analysis

Verbal communication

Written communication

MS Office

Education

Bachelor's degree in Healthcare-related field

RN/LPN license

CPC/CRC/RHIA/RHIT/CCS certification

Tools

Regulatory references / CMS guidelines

Job description

Highmark Health in the United States seeks a healthcare quality professional to lead process improvement, documentation, and coding initiatives across product lines. You will work with compliance and medical record departments to enhance care quality and STAR ratings.

The role requires an RN/LPN license or equivalent, a healthcare degree, and coding certifications or the ability to obtain them within four months. Expect audits, training, and cross-functional collaboration.