Clinical Quality & Compliance Analyst: HEDIS & Coding

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

Job summary

Highmark Health seeks a quality and compliance professional to collaborate with clinical and administrative teams. You will drive process improvements and oversee medical record reviews, HCC coding, and support STARS and accreditation initiatives.

Responsibilities include audits, provider education on documentation standards, and coordinating credentialing activities, ensuring HIPAA compliance. Office-based with 0–25% travel.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a healthcare field.
• 6 years of HEDIS/Quality abstraction, HCC Coding, or healthcare field in lieu of bachelor's degree.
• CPC, CRC, RHIA, RHIT, or CCS certification within 4 months of hire.

Responsibilities

• Develop and manage process improvement initiatives using data analysis, process analysis, and coding.
• Conduct audits and data analysis to improve STARS, value-based care and accreditation.
• Monitor changes in CMS guidelines and adjust the compliance plan accordingly.
• Educate providers on STARS, HEDIS, and HCC Coding; conduct re-audits as needed.
• Coordinate credentialing and site visits as requested.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical thinking

Problem solving

Education

RN or LPN license or Bachelor's in healthcare

CPC/CRC/RHIA/RHIT/CCS certification

Job description

Highmark Health seeks a quality and compliance professional to collaborate with clinical and administrative teams. You will drive process improvements and oversee medical record reviews, HCC coding, and support STARS and accreditation initiatives.

Responsibilities include audits, provider education on documentation standards, and coordinating credentialing activities, ensuring HIPAA compliance. Office-based with 0–25% travel.