Clinical Quality & Compliance Analyst (HEDIS, HCC Coding)

Highmark Health; Lorida (FL); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. seeks a Quality Improvement Specialist to drive process improvements across compliance, coding, and documentation to support quality measures and member care.

The role involves audits, education for providers, and coordination with credentialing and accreditation programs to enhance STARS and value-based care. Strong knowledge of CMS guidelines and HCC coding is required.

Qualifications

• Current RN or LPN license or Bachelor’s degree in a healthcare-related field.
• 6 years of experience with HEDIS/Quality abstraction, HCC coding, or healthcare-related field in lieu of bachelor.
• Certification in CPC, CRC, RHIA, RHIT, or CCS or must obtain within 4 months after hire.

Responsibilities

• Develop and manage process improvement initiatives with data analysis and reporting.
• Analyze data from reviews to improve documentation and coding for members.
• Monitor regulatory and accrediting requirements; adjust compliance plans accordingly.
• Conduct retrospective, concurrent, and prospective audits; educate providers on STARS, HEDIS, HCC Coding.
• Perform other duties as assigned.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical skills

Education

RN or LPN license

Bachelor’s degree in a healthcare-related field

CPC/CRC/RHIA/RHIT/CCS certification or must obtain within 4 months

6 years HEDIS/Quality abstraction or HCC coding experience in lieu of bachelor

Tools

Microsoft Office suite

Job description

Highmark Inc. seeks a Quality Improvement Specialist to drive process improvements across compliance, coding, and documentation to support quality measures and member care.

The role involves audits, education for providers, and coordination with credentialing and accreditation programs to enhance STARS and value-based care. Strong knowledge of CMS guidelines and HCC coding is required.