Clinical Quality Improvement & Compliance Analyst

Highmark Health; Wilmington (VT); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health is seeking a qualified professional to improve documentation and coding accuracy across multiple departments. The role emphasizes HCC coding, HEDIS, STARS, and compliance with CMS/NQCA standards while coordinating credentialing and audits.

You will lead education for providers, conduct various audits, and help ensure high-quality care and efficient processes across product lines.

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.
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire.

Responsibilities

• Develop and manage process improvement initiatives for members and providers with data analysis and reporting.
• Conduct data collection and analysis from office site/medical record reviews to improve care and coding accuracy.
• Coordinate with revenue programs, credentialing, and quality improvement to improve STARS and value-based care.
• Perform audits (retrospective, concurrent, prospective) and communicate gaps and results.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.

Skills

Total Quality Management

Statistics

Verbal & written communication

Microsoft Office

Analytical problem solving

Education

RN/LPN license or healthcare bachelor

6 years HEDIS/Quality abstraction or HCC coding experience in lieu of degree

CPC/CRC/RHIA/RHIT/CCS certification (or within 4 months)

Tools

Microsoft Office

Electronic Health Records (EHR)

Job description

Highmark Health is seeking a qualified professional to improve documentation and coding accuracy across multiple departments. The role emphasizes HCC coding, HEDIS, STARS, and compliance with CMS/NQCA standards while coordinating credentialing and audits.

You will lead education for providers, conduct various audits, and help ensure high-quality care and efficient processes across product lines.