Clinical Quality Improvement & Compliance Analyst

Highmark Health; Central City (NE); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a qualified professional to advance process improvements across compliance, coding, and quality initiatives. The role focuses on accurate ICD-10-CM coding, documentation enhancement, and education for providers and staff.

Responsibilities include data-driven process optimization, auditing for STARS/HEDIS, and coordinating with credentialing and quality programs to support accreditation and value-based care. Travel may be required occasionally.

Qualifications

• RN or LPN license or Bachelor's degree in a Healthcare-related field is required
• Minimum 3 years in nursing or a healthcare-related field
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months of hire
• HEDIS/Quality abstraction and HCC Coding experience 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 concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical skills

Education

RN or LPN license or healthcare bachelor

Tools

MS Office

Job description

Highmark Inc. is seeking a qualified professional to advance process improvements across compliance, coding, and quality initiatives. The role focuses on accurate ICD-10-CM coding, documentation enhancement, and education for providers and staff.

Responsibilities include data-driven process optimization, auditing for STARS/HEDIS, and coordinating with credentialing and quality programs to support accreditation and value-based care. Travel may be required occasionally.