Clinical Quality & Compliance Analyst – Quality Improvement

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

Job summary

Highmark Inc. is seeking a professional to support compliance, process improvement, medical record review, and coding initiatives across product lines. The role focuses on improving documentation for ICD-10-CM coding, provider education, and accreditation activities.

You will coordinate audits, reviews, and targeted studies to enhance STARs and value-based care. The position requires RN/LPN licensure or a healthcare bachelor’s degree, with strong analytics, data analysis, and communication

Qualifications

• Current state 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's degree
• 3 years of nursing or healthcare-related field

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

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical and problem-solving

Education

Bachelor’s degree in a Healthcare-related field

RN or LPN license

CPC, CRC, RHIA, RHIT or CCS certification

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a professional to support compliance, process improvement, medical record review, and coding initiatives across product lines. The role focuses on improving documentation for ICD-10-CM coding, provider education, and accreditation activities.

You will coordinate audits, reviews, and targeted studies to enhance STARs and value-based care. The position requires RN/LPN licensure or a healthcare bachelor’s degree, with strong analytics, data analysis, and communication