Clinical Quality & Compliance Innovator

Highmark Health; Tennessee; Remote; USD 63.000 - 97.000; Vollzeit

Zusammenfassung

Highmark Health seeks a quality improvement professional to advance documentation, coding accuracy, and care quality across product lines. The role focuses on educating providers, conducting medical record reviews, and performing audits to strengthen STARS and value-based care.

The incumbent will coordinate credentialing-related activities, support compliance with CMS and NCQA standards, and lead process-improvement initiatives with a focus on quality outcomes and member satisfaction.

Qualifikationen

• 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/medical coding, or healthcare related field in lieu of bachelor's degree.
• 3 years of nursing or healthcare-related field
• 1 year of project management experience (preferred)
• Medicaid/Medicare experience (preferred)
• Managed Care Organizations experience (preferred)

Aufgaben

• Develop and manage process improvement initiatives from the Organization for member and providers, including detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct, collect and analyze information from office site and/or medical record reviews to improve care, services, documentation and coding for members.
• Monitor regulatory/accrediting body requirements and adjust the compliance plan to CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective audits and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.

Kenntnisse

TQM concepts

Statistics

Verbal communication

Written communication

Analytical skills

Microsoft Office

Ausbildung

RN or LPN license

Bachelor's degree in healthcare

Tools

Microsoft Office

Jobbeschreibung

Highmark Health seeks a quality improvement professional to advance documentation, coding accuracy, and care quality across product lines. The role focuses on educating providers, conducting medical record reviews, and performing audits to strengthen STARS and value-based care.

The incumbent will coordinate credentialing-related activities, support compliance with CMS and NCQA standards, and lead process-improvement initiatives with a focus on quality outcomes and member satisfaction.