Clinical Quality Management Analyst - RN (Remote)

Highmark Health; Iowa City (IA); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. in the Iowa City area is seeking a compliance-focused professional to work with departments across compliance, process improvement, medical record review, and coding to enhance quality of care and documentation.

The role emphasizes educating providers on CMS, NCQA standards, HEDIS, and HCC coding, conducting audits, site visits, and supporting STARS initiatives with data analyses and best practices.

Qualifications

• Current state RN or LPN licensure or Bachelor's degree in healthcare field.
• Substitutions: 6 years of experience in HEDIS/quality abstraction or HCC coding in lieu of degree.
• 3 years of nursing or healthcare-related experience.
• Medicaid/Medicare experience preferred.
• Experience with Managed Care Organizations preferred.

Responsibilities

• Develop and manage process improvement initiatives for member and provider quality data.
• Conduct audits and reviews to improve documentation and ICD-10-CM coding.
• Monitor regulatory/accrediting requirements and adjust the compliance plan.
• Educate providers on STARS, HEDIS, and HCC coding.
• Coordinate credentialing and related activities as requested.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Data analysis

Education

RN or LPN license

Bachelor's degree in healthcare

Tools

Microsoft Office

Job description

Company

Highmark Inc.

Job Description

JOB SUMMARY

This job works with appropriate departments in the areas of compliance, process improvement, medical record review and coding, and member and provider satisfaction for all product lines. Recommends and implements process improvements related to the potential of quality medical care and service to members and to improve documentation of these services for appropriate ICD 10-CM coding. Serves as a resource and educator regarding provider and office staff medical record documentation, federal and state standards including CMS and NCQA standards and continuous quality improvement principles. Perform special studies per audits, conducting office site visits and medical records reviews, ensuring improvement in performance for various initiatives in a timely manner. May coordinate credentialing, re-credentialing, member complaint investigations, Medical Director site visit requests, facility site visit requests, activities to include other reviews, audits, accreditation activities as requested on behalf of the organization.

ESSENTIAL 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.

EDUCATION

• 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
• PreferredNone
• EXPERIENCERequired3 years of nursing or healthcare-related field
• Preferred1 year of project management experience
• Medicaid/Medicare experience
• Preferred experience with Managed Care Organizations

LICENSES OR CERTIFICATIONS

• RequiredCurrent State RN or LPN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), ORCPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• PreferredRN with an active compact license

SKILLS

An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurementsAn understanding of statistics is also preferred to analyze various reports and validate study methodologiesExcellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles. Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring, and problem resolution.Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)Well-developed, analytical and problem-solving skills with the ability to understand and interpret clinical dataLanguage (Other than English):NoneTravel Requirement:0% - 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice-basedTeaches / trains others regularOcOccasionallyTravel regularly from the office to various work sites or from site-to-siteRarelyWorks primarily out-of-the office selling products/services (sales employees)NeverPhysical work site requiredYesLifting: up to 10 poundsConstantlyLifting: 10 to 25 poundsOccasionallyLifting: 25 to 50 poundsNever

Disclaimer

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:$62,700.00

Pay Range Maximum:$97,200.00

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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