Clinical Quality Improvement Analyst

Highmark Health; Philadelphia (Philadelphia County); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. in Philadelphia is seeking a quality and coding professional to enhance process improvements across compliance, coding accuracy, and member/provider satisfaction.

You will review medical records and ensure accurate ICD-10-CM coding while educating staff on CMS and NCQA standards. The role includes audits, data analysis, ongoing education for providers on STARS, HEDIS, and HCC coding, and collaboration with credentialing and quality programs.

Qualifications

• RN or LPN license or healthcare-related bachelor's degree required.
• CPC/CRC/RHIA/RHIT/CCS certification or obtaining within 4 months after hire.
• Experience with HEDIS/quality abstraction and medical coding preferred.

Responsibilities

• Develop and manage process improvement initiatives with data analysis and reporting.
• Review medical records and assign ICD-10-CM codes for chronic conditions.
• Educate providers on STARS, HEDIS, and HCC coding and CMS/NCQA standards.
• Conduct audits (retrospective, concurrent, annual) and identify gaps.
• Coordinate credentialing activities and quality improvement programs.
• Monitor regulatory changes and adjust compliance plans accordingly.
• Perform other duties as assigned.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical thinking

Problem solving

Education

Bachelor's degree in healthcare field

RN or LPN licensure

eNLC multi-state licensure (preferred)

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

Job description

Highmark Inc. in Philadelphia is seeking a quality and coding professional to enhance process improvements across compliance, coding accuracy, and member/provider satisfaction.

You will review medical records and ensure accurate ICD-10-CM coding while educating staff on CMS and NCQA standards. The role includes audits, data analysis, ongoing education for providers on STARS, HEDIS, and HCC coding, and collaboration with credentialing and quality programs.