Clinical Quality Management Analyst - RN (Remote)

Highmark Health; Pennsylvania; Hybrid; USD 63,000 - 97,000; Full time

Job summary

Highmark Health is seeking aCompliance Specialist focused on quality improvement, coding accuracy, and regulatory adherence. The role collaborates with nursing staff, medical directors, and office personnel to improve documentation and coding accuracy, supporting CMS, NCQA standards and STARs metrics.

The position emphasizes data analysis, audits, education, and continuous process improvement across multiple departments; travel up to 25% is possible in a variety of care settings.

Qualifications

• RN or LPN license or healthcare-related bachelor's degree required.
• Substitutions: 6 years of experience with HEDIS/Quality abstraction, HCC Coding, or healthcare-related field in lieu of bachelor's degree.
• Preferred RN with an active compact license.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, reporting, documentation, and HCC coding.
• Analyze information from audits to improve care, documentation, and coding for members; assign ICD-10-CM codes for chronic conditions.
• Monitor regulatory and accrediting requirements and adjust the compliance plan to CMS guidelines.
• Conduct audits and communicate results; perform re-audits as needed.
• Educate providers on STARS, HEDIS, and HCC coding.
• Other duties as assigned.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Interpersonal communication

Computer literacy

MS Office

Analytical skills

Problem solving

Travel ability

Education

RN or LPN license

Bachelor’s degree in Healthcare field

Tools

Microsoft Office

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

Required 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

Preferred None

EXPERIENCE

Required 3 years of nursing or healthcare-related field

Preferred 1 year of project management experience Medicaid/Medicare experience Preferred experience with Managed Care Organizations

LICENSES OR CERTIFICATIONS

Required Current State RN or LPN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), OR CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire

Preferred RN with an active compact license

SKILLS

• An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements
• An understanding of statistics is also preferred to analyze various reports and validate study methodologies
• Excellent 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 data
• Language (Other than English): None Travel Requirement: 0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type Office-based Teaches / trains others regularly

Occasionally Travel regularly from the office to various work sites or from site-to-site

Rarely Works primarily out-of-the office selling products/services (sales employees)

Never Physical work site required Yes Lifting: up to 10 pounds Constantly Lifting: 10 to 25 pounds Occasionally Lifting: 25 to 50 pounds Never

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.

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.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services.

Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.