Clinical Quality Improvement & Compliance Analyst

Highmark Health; Fulton (MS); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a quality-focused professional to enhance documentation, coding accuracy, and provider education. You will collaborate with compliance, medical record review, and revenue programs to support STARS and HEDIS initiatives while upholding CMS and NCQA standards.

The role requires RN/LPN licensure or a healthcare bachelor’s, 3 years in healthcare, and significant HEDIS/HCC coding exposure. You will lead audits and credentialing support as needed.

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 required.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct information and data analysis from office site/record reviews to improve care and documentation and assign ICD10-CM codes.
• Monitor regulatory and accrediting requirements; adjust compliance plan to CMS Coding Guidelines.
• Conduct audits (retrospective, concurrent, prospective) and provide continuing education to providers on STARS, HEDIS, and HCC Coding.

Skills

Quality improvement

Data analysis

Coding knowledge

Communication skills

Office software

Education

RN/LPN license

Bachelor's degree in healthcare

Tools

HEDIS

HCC Coding

Job description

Highmark Inc. is seeking a quality-focused professional to enhance documentation, coding accuracy, and provider education. You will collaborate with compliance, medical record review, and revenue programs to support STARS and HEDIS initiatives while upholding CMS and NCQA standards.

The role requires RN/LPN licensure or a healthcare bachelor’s, 3 years in healthcare, and significant HEDIS/HCC coding exposure. You will lead audits and credentialing support as needed.