Clinical Quality & Compliance Analyst RN

Highmark Health

Jackson (MS)

Remote

USD 63,000 - 97,000

Full time

7 days ago

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Job summary

Highmark Inc. is seeking a qualified professional to support compliance, process improvement, medical record review, and coding across product lines. The role emphasizes accurate ICD-10-CM coding, documentation enhancement, and educating providers on CMS/NCQA standards.

Experience in HEDIS, HCC coding, and coding audits is essential. The position requires RN/LPN licensure or a healthcare degree, plus 3 years in nursing or a related field, with certifications or a plan to obtain them within 4

Qualifications

Current state RN or LPN license or Bachelor's degree in a Healthcare-related field is required.
6 years of experience with HEDIS/Quality abstraction, HCC Coding, or healthcare-related field in lieu of a bachelor’s degree.
CPC, CRC, RHIA, RHIT, or CCS certification or must obtain within 4 months of hire.

Responsibilities

Develop and manage process improvement initiatives with data analysis, process analysis, reporting, and coding.
Conduct site and records reviews to improve care documentation and coding for members; coordinate with revenue, credentialing, and quality programs.
Monitor regulatory/ accreditation requirements and update the compliance plan to CMS guidelines.
Perform retrospective, concurrent, and prospective audits; conduct education for providers on STARS, HEDIS, and HCC Coding; conduct re-audits as needed.
Other duties as assigned.