Clinical Quality & Compliance Analyst (HEDIS/HCC)

Highmark Health; Minneota (MN); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health seeks a professional to lead process improvements across compliance, quality, and coding functions. The role emphasizes accurate ICD-10-CM coding, education of providers, and driving STARs and value-based care initiatives.

The position involves data analysis, audits (retrospective/concurrent/prospective), and coordination with credentialing and quality programs. Strong knowledge of CMS/NCQA standards is expected.

Qualifications

• 3 years of nursing or healthcare-related field.
• Required current RN or LPN license or healthcare-related bachelor’s degree.
• Willingness to conduct audits, provider education, and data-driven process improvements.

Responsibilities

• Develop and manage process improvement initiatives for members and providers.
• Analyze data from office site and medical record reviews to improve care and coding.
• Educate providers on STARS, HEDIS, and HCC coding; conduct audits and re-audits.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Problem solving

Education

Bachelor’s degree in a Healthcare-related field

RN or LPN license

Tools

CRM systems

Office software

Job description

Highmark Health seeks a professional to lead process improvements across compliance, quality, and coding functions. The role emphasizes accurate ICD-10-CM coding, education of providers, and driving STARs and value-based care initiatives.

The position involves data analysis, audits (retrospective/concurrent/prospective), and coordination with credentialing and quality programs. Strong knowledge of CMS/NCQA standards is expected.