Clinical Quality & Compliance Analyst (Process Improvement)

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

Job summary

Highmark Health is seeking a Quality Improvement professional to collaborate with compliance, process improvement, medical record review, coding, and provider satisfaction across product lines. The role focuses on improving documentation, ensuring ICD-10-CM coding accuracy, and supporting quality ratings such as STARS and value-based care.

The ideal candidate will have RN/LPN or healthcare degree, 3 years of related experience, and relevant coding/certification credentials.

Qualifications

• RN or LPN license or Bachelor’s degree in a healthcare-related field.
• 3 years of nursing or healthcare-related experience required.
• CPC, CRC, RHIA, RHIT or CCS certification (or must obtain within 4 months).
• Experience with HEDIS/Quality abstraction and coding is preferred.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, process analysis, report generation, documentation, and HCC coding.
• Conduct audits (retrospective/concurrent/prospective) and communicate results; educate providers on STARS, HEDIS, and HCC Coding.
• Monitor regulatory/accrediting requirements and adjust the compliance plan accordingly.
• Coordinate credentialing activities and support quality improvement programs.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Computer literacy

MS Office

Analytical problem solving

Education

RN or LPN license

Bachelor’s degree in Healthcare-related field

Tools

HEDIS data abstraction

EHR systems

Medical coding software

Job description

Highmark Health is seeking a Quality Improvement professional to collaborate with compliance, process improvement, medical record review, coding, and provider satisfaction across product lines. The role focuses on improving documentation, ensuring ICD-10-CM coding accuracy, and supporting quality ratings such as STARS and value-based care.

The ideal candidate will have RN/LPN or healthcare degree, 3 years of related experience, and relevant coding/certification credentials.