Clinical Quality Improvement Analyst (HEDIS & HCC Coding)

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

Job summary

Highmark Health seeks a healthcare quality and compliance professional to collaborate with compliance, process improvement, medical record review and coding teams. You will support ICD-10-CM coding accuracy, CMS/NCQA standards, and continuous quality improvement through audits and education.

Responsibilities include provider education, credentialing coordination, site visits, and coordinating reviews to improve STARS, value-based care and overall member satisfaction.

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.

Responsibilities

• Develop and manage process improvement initiatives with 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 care, services, documentation and coding for members.
• Monitor regulatory/accrediting body requirements and adjust the compliance plan to CMS Coding Guidelines.
• Conduct audits (retrospective, concurrent, prospective, semi-annual, annual) and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.
• Coordinate credentialing and re-credentialing, and site visits as requested.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Computer literacy

Microsoft Office

Clinical data analysis

Education

RN or LPN license OR Bachelor's degree in Healthcare

Tools

Microsoft Office

Job description

Highmark Health seeks a healthcare quality and compliance professional to collaborate with compliance, process improvement, medical record review and coding teams. You will support ICD-10-CM coding accuracy, CMS/NCQA standards, and continuous quality improvement through audits and education.

Responsibilities include provider education, credentialing coordination, site visits, and coordinating reviews to improve STARS, value-based care and overall member satisfaction.