Clinical Quality Improvement Analyst – HEDIS & HCC

Highmark Health; Bristol (RI); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a Quality Improvement Specialist to work with compliance, process improvement, coding, and member/provider satisfaction across product lines. Recommends and implements process improvements related to quality medical care and documentation for ICD-10-CM coding.

Serves as a resource and educator on CMS/NCQA standards and continuous quality improvement. This role conducts audits, education, and coordination of credentialing/quality activities to improve STARS, value-based

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, or healthcare related field in lieu of bachelor’s degree
• 3 years of nursing or healthcare-related field
• Current State RN or LPN licensure OR multi-state licensure through eNLC, OR CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• RN with an active compact license preferred

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 knowledge

Statistics

Communication skills

MS Office

Analytical skills

Education

RN/LPN license or healthcare bachelor's

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a Quality Improvement Specialist to work with compliance, process improvement, coding, and member/provider satisfaction across product lines. Recommends and implements process improvements related to quality medical care and documentation for ICD-10-CM coding.

Serves as a resource and educator on CMS/NCQA standards and continuous quality improvement. This role conducts audits, education, and coordination of credentialing/quality activities to improve STARS, value-based