Clinical Quality Improvement Analyst

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

Job summary

Highmark Health is seeking a compliance and quality improvement professional to collaborate with clinical and administration teams. The role focuses on nursing-based documentation, ICD-10-CM coding accuracy, and adherence to CMS/NCQA standards while driving quality improvement initiatives across programs.

You will lead audits, provide education on STARS/HEDIS/HCC coding, and coordinate credentialing activities, with a strong emphasis on data-driven process improvements and interdepartmental

Qualifications

• Current 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
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• RN with an active compact license

Responsibilities

• Develop and manage process improvement initiatives from the Organization including data analysis and report generation.
• Conduct medical record reviews to improve documentation, coding, and STARS score.
• Monitor changes in CMS/NCQA guidelines and adjust compliance plans.
• Perform audits (retrospective, concurrent, prospective) and educate providers on STARS/HEDIS/HCC coding.
• Coordinate credentialing, re-credentialing, and related reviews as requested.

Education

RN or LPN license or Bachelor’s degree in a Healthcare-related field

eNLC multi-state licensure

CPC/CRC/RHIA/RHIT/CCS certification (or within 4 months)

3 years nursing/healthcare experience

6 years HEDIS/Quality abstraction or HCC coding in lieu of bachelor

Tools

Microsoft Office (Word, Excel, Access, PowerPoint)

Job description

Highmark Health is seeking a compliance and quality improvement professional to collaborate with clinical and administration teams. The role focuses on nursing-based documentation, ICD-10-CM coding accuracy, and adherence to CMS/NCQA standards while driving quality improvement initiatives across programs.

You will lead audits, provide education on STARS/HEDIS/HCC coding, and coordinate credentialing activities, with a strong emphasis on data-driven process improvements and interdepartmental