Clinical Quality & Compliance Analyst (HEDIS/HCC)

Highmark Health; Crystal Bay (NV); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health in Nevada seeks a quality and compliance professional to lead process improvement, medical record review, and coding initiatives across product lines, focusing on accurate ICD-10-CM coding and STARS performance.

You will educate providers and office staff on documentation standards, coordinate audits, credentialing activities, and support ongoing quality improvement in a fast-paced healthcare environment.

Qualifications

• Bachelor’s degree required; substitutions: ~6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor's degree

Responsibilities

• Develop and manage process improvement initiatives from the Organization for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and achieve and maintain accreditation.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan to follow CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective, semi-annual, and annual audits, identify gaps and communicate results.
• Conduct continuing education to providers on STARS, HEDIS, and HCC Coding.
• Conduct re-audits as needed.
• Other duties as assigned or requested.

Skills

Total Quality Management

Statistics

Verbal comms

Written comms

MS Office

Analytical skills

Education

Bachelor’s degree in a Healthcare-related field

Job description

Highmark Health in Nevada seeks a quality and compliance professional to lead process improvement, medical record review, and coding initiatives across product lines, focusing on accurate ICD-10-CM coding and STARS performance.

You will educate providers and office staff on documentation standards, coordinate audits, credentialing activities, and support ongoing quality improvement in a fast-paced healthcare environment.