Clinical Quality & Compliance Analyst – HEDIS & Coding

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

Job summary

Highmark Inc. in Maine seeks a healthcare quality and compliance professional to collaborate across departments on data analysis, documentation, and coding for ICD-10-CM.

This role emphasizes process improvements and education to enhance care quality and documentation standards. You will lead audits (retrospective, concurrent, and prospective), educate providers on STARS, HEDIS, and HCC coding, and support credentialing and reviews as needed.

Qualifications

• Current RN or LPN license or Bachelor's degree in a Healthcare-related field.
• 3 years of nursing or healthcare-related field experience.
• CPC, CRC, RHIA, RHIT, or CCS certification or must obtain within 4 months upon hire.

Responsibilities

• Develop and manage process improvement initiatives from the Organization for member and providers, including data analysis, process analysis, report generation, medical record documentation, and HCC coding.
• Conduct information and data from office site and/or medical record reviews to continually improve care, documentation, and coding for members; coordinate with revenue, credentialing, and quality improvement programs.
• Monitor regulatory/accrediting changes and adjust the compliance plan to CMS Coding Guidelines; conduct audits and provide continuing education on STARS, HEDIS, and HCC coding.

Skills

TQM concepts

Statistics

Verbal communication

Microsoft Office

Analytical skills

Education

Bachelor's degree in a Healthcare-related field

RN or LPN license (required)

Job description

Highmark Inc. in Maine seeks a healthcare quality and compliance professional to collaborate across departments on data analysis, documentation, and coding for ICD-10-CM.

This role emphasizes process improvements and education to enhance care quality and documentation standards. You will lead audits (retrospective, concurrent, and prospective), educate providers on STARS, HEDIS, and HCC coding, and support credentialing and reviews as needed.