Clinical Quality & Process Improvement Analyst

Highmark Health; Butlerville (IN); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. works with compliance, process improvement, medical record review and coding teams to ensure high-quality care and accurate ICD-10-CM coding across product lines. The role emphasizes enhancing member and provider satisfaction and coordinating accreditation-related activities.

Responsibilities include conducting audits, educating providers on STARS and CMS standards, and implementing process improvements to support quality initiatives in a timely manner.

Qualifications

• RN or LPN license or Bachelor's in healthcare field
• Substitution: 6 years experience in HEDIS/Quality abstraction or HCC coding in lieu of bachelor
• 3 years nursing/healthcare-related field
• CPC, CRC, RHIA, RHIT or CCS certification or must obtain within 4 months of hire
• Preferred Medicaid/Medicare experience or Managed Care exposure

Responsibilities

• Develop and manage process improvement initiatives using data analysis, reporting and documentation.
• Analyze office site and medical record reviews to improve care, documentation and coding.
• Monitor regulatory changes and adjust the compliance plan per CMS guidelines.
• Conduct retrospective, concurrent and prospective audits and educate providers on STARS and HCC coding.
• Coordinate credentialing activities and support quality improvement programs.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Data analysis

Problem solving

Education

Bachelor’s degree in a Healthcare-related field

Job description

Highmark Inc. works with compliance, process improvement, medical record review and coding teams to ensure high-quality care and accurate ICD-10-CM coding across product lines. The role emphasizes enhancing member and provider satisfaction and coordinating accreditation-related activities.

Responsibilities include conducting audits, educating providers on STARS and CMS standards, and implementing process improvements to support quality initiatives in a timely manner.