Clinical Quality & Compliance Analyst (HEDIS/HCC Coding)

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

Job summary

Highmark Health is seeking a quality and compliance professional to lead process improvements across compliance, coding and documentation initiatives. You will analyze data, conduct medical record reviews, and educate providers on CMS and NCQA standards to improve STARS, HEDIS and HCC coding.

The role involves auditing, credentialing coordination, and collaboration with medical staff to ensure accurate documentation and coding across all product lines, while aligning with improvement goals and

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-related field.
• Substitutions: 6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor's degree.
• Preferred: None

Responsibilities

• Develop and manage process improvement initiatives with 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 improve care, documentation and coding for members.
• Monitor regulatory/accrediting changes and adjust the compliance plan to CMS Coding Guidelines.
• Conduct retrospective, concurrent and prospective audits, identify gaps and communicate results.
• Provide continuing education to providers on STARS, HEDIS and HCC Coding; perform re-audits as needed.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical skills

Education

Current state RN or LPN license or Bachelor's degree in a Healthcare-related field

Tools

Microsoft Office Suite

Job description

Highmark Health is seeking a quality and compliance professional to lead process improvements across compliance, coding and documentation initiatives. You will analyze data, conduct medical record reviews, and educate providers on CMS and NCQA standards to improve STARS, HEDIS and HCC coding.

The role involves auditing, credentialing coordination, and collaboration with medical staff to ensure accurate documentation and coding across all product lines, while aligning with improvement goals and