Clinical Quality Improvement Analyst

Highmark Health; Portland (ME); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a Quality Improvement Analyst to work with compliance, process improvement, medical record review, coding, and provider satisfaction across product lines.

You will drive data analysis, documentation improvements, and ICD-10-CM coding accuracy while supporting accreditation efforts and STARS/HEDIS initiatives. You will conduct audits, educate providers on coding standards, and coordinate credentialing activities as needed, ensuring timely performance improvements and

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-related field.
• Substitutions: 6 years of experience with HEDIS/Quality abstraction, HCC Coding/medical coding, or healthcare related field in lieu of bachelor's degree.
• Medicaid/Medicare experience; Preferred experience with Managed Care Organizations.
• Experience: 3 years of nursing or healthcare-related field; Preferred 1 year of project management experience.

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, documentation and proper coding.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and adjust the compliance plan to CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective 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

Quality improvement

Data analysis

Regulatory knowledge

Communication skills

Education/training

Education

RN/LPN licensure or ENLC multistate licensure

Bachelor's degree in healthcare-related field

CPC/CRC/RHIA/RHIT/CCS or equivalent

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a Quality Improvement Analyst to work with compliance, process improvement, medical record review, coding, and provider satisfaction across product lines.

You will drive data analysis, documentation improvements, and ICD-10-CM coding accuracy while supporting accreditation efforts and STARS/HEDIS initiatives. You will conduct audits, educate providers on coding standards, and coordinate credentialing activities as needed, ensuring timely performance improvements and