Clinical Quality & Compliance Specialist

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

Job summary

Highmark Inc. is seeking a healthcare quality and compliance professional to advance process improvements across departments, focusing on documentation, coding, and member/provider satisfaction.

The role emphasizes HCC coding, STARS, and CMS/HIPAA standards while coordinating credentialing and audits. The successful candidate will lead education for providers, perform audits, and support accreditation initiatives.

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/medical coding, or healthcare related field in lieu of bachelor's degree
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire

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

MS Office

Analytical skills

Education

RN or LPN license

Bachelor’s degree in Healthcare-related field

Tools

EMR systems

ICD-10-CM terminology

Job description

Highmark Inc. is seeking a healthcare quality and compliance professional to advance process improvements across departments, focusing on documentation, coding, and member/provider satisfaction.

The role emphasizes HCC coding, STARS, and CMS/HIPAA standards while coordinating credentialing and audits. The successful candidate will lead education for providers, perform audits, and support accreditation initiatives.