Clinical Quality Improvement & Coding Analyst

Highmark Health; Charlotte (NC); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a Quality Improvement professional to support compliance, process improvement, medical record review, and coding across product lines.

You will implement process improvements to enhance quality of care and documentation for ICD-10-CM coding, serving as a resource on CMS and NCQA standards and HCC coding. The role includes education for providers, audits, and coordination with credentialing and quality programs to improve STARS and value-based care, with opportunities to

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/medical coding, or healthcare related field in lieu of bachelor's degree
• 3 years of nursing or healthcare-related field
• 1 year of project management experience
• Medicaid/Medicare experience
• Preferred experience with Managed Care Organizations
• 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 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

Verbal communication

Written communication

MS Office

Analytical thinking

Education

RN/LPN license or healthcare bachelor's

CPC/CRC/RHIA/RHIT/CCS certification

Job description

Highmark Inc. is seeking a Quality Improvement professional to support compliance, process improvement, medical record review, and coding across product lines.

You will implement process improvements to enhance quality of care and documentation for ICD-10-CM coding, serving as a resource on CMS and NCQA standards and HCC coding. The role includes education for providers, audits, and coordination with credentialing and quality programs to improve STARS and value-based care, with opportunities to