Clinical Quality & HEDIS Improvement Analyst

Highmark Health; Honolulu (HI); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a Compliance/Nurse Auditor to collaborate with departments on compliance, process improvement, medical record review, coding, and member/provider satisfaction across product lines.

The role focuses on improving documentation for ICD-10-CM coding and advancing quality initiatives. The position involves educating staff on CMS and NCQA standards and leading audits and studies as requested by the organization.

Qualifications

• RN or LPN license or healthcare-related Bachelor's degree.
• 3 years of nursing or healthcare-related experience required.
• Experience with Medicaid/Medicare is preferred.
• Knowledge of HEDIS and HCC coding is beneficial.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, reporting, documentation, and HCC coding.
• Conduct audits and reviews to improve STARS, value-based care, and accreditation.
• Monitor regulatory and accreditation requirements and adjust the compliance plan accordingly.
• Perform retrospective, concurrent, and prospective audits and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC coding.
• Conduct re-audits as needed.
• Coordinate other reviews and accreditation activities.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Data analysis

Problem solving

Education

RN or LPN license or healthcare-related bachelor's

HEDIS/Quality abstraction experience

3 years nursing/healthcare experience

Project management experience

Medicaid/Medicare experience

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a Compliance/Nurse Auditor to collaborate with departments on compliance, process improvement, medical record review, coding, and member/provider satisfaction across product lines.

The role focuses on improving documentation for ICD-10-CM coding and advancing quality initiatives. The position involves educating staff on CMS and NCQA standards and leading audits and studies as requested by the organization.