Clinical Quality Improvement & Compliance Analyst

Highmark Health; Wisconsin; Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health is seeking a compliance and quality improvement professional to lead process improvement initiatives across departments, focusing on documentation quality, ICD-10-CM coding, and provider education. You will support audits, credentialing, and accreditation efforts to improve STARS and value-based care.

The role requires RN/LPN license or healthcare degree with experience in HEDIS, HCC coding, and quality abstraction.

Qualifications

• Current state RN or LPN license or Bachelor’s degree in a Healthcare-related field.
• Substitutions: ~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.
• 1 year of project management experience preferred.
• Medicaid/Medicare experience preferred.
• Managed Care Organization experience preferred.
• Current state RN or LPN licensure OR current multi-state licensure through eNLC, OR CPC, CRC, RHIA, RHIT, or CCS certification or must obtain within 4 months upon hire.
• RN with an active compact license 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 reviews and audits to continually improve care, documentation and coding for members, coordinating with revenue programs, credentialing and quality improvement to enhance STARS and value-based care.
• Monitor regulatory and accrediting requirements and adjust the compliance plan to CMS guidelines.
• Perform retrospective, concurrent, and prospective audits and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.
• Conduct re-audits as needed.
• Coordinate credentialing and related activities as requested.

Skills

TQM concepts

Statistics

Verbal & written communication

MS Office

Data analysis

Education

RN/LPN license or Healthcare Bachelor's

6 years HEDIS/Quality abstraction or related field

CPC/CRC/RHIA/RHIT/CCS certifications

Tools

Microsoft Office

Job description

Highmark Health is seeking a compliance and quality improvement professional to lead process improvement initiatives across departments, focusing on documentation quality, ICD-10-CM coding, and provider education. You will support audits, credentialing, and accreditation efforts to improve STARS and value-based care.

The role requires RN/LPN license or healthcare degree with experience in HEDIS, HCC coding, and quality abstraction.