Clinical Quality Improvement & Coding Analyst

Highmark Health; Kansas City (MO); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. in the United States is seeking a compliance/quality improvement professional to support coding, documentation, and audit activities across product lines.

You will drive process improvements, ensure accurate ICD-10-CM coding, and educate providers on standards including CMS and NCQA requirements. Responsibilities include data analysis, conducting site reviews and medical record audits, and coordinating credentialing and accreditation efforts to enhance STARs and value-based care.

Qualifications

• RequiredCurrent state RN or LPN license or Bachelor’s degree in a Healthcare-related field
• Substitutions6 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
• RN or LPN licensure OR multi-state licensure through eNLC, ORCPC, 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

Process Improvement

Data Analysis

HCC Coding

Audits

Education

RN or LPN license

Bachelor’s degree in Healthcare-related field

Substitutions: 6 years experience in lieu of degree

Job description

Highmark Inc. in the United States is seeking a compliance/quality improvement professional to support coding, documentation, and audit activities across product lines.

You will drive process improvements, ensure accurate ICD-10-CM coding, and educate providers on standards including CMS and NCQA requirements. Responsibilities include data analysis, conducting site reviews and medical record audits, and coordinating credentialing and accreditation efforts to enhance STARs and value-based care.