Clinical Quality & Process Improvement Analyst

Highmark Health; Carson City (NV); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health seeks a healthcare quality and compliance professional to lead process improvement across coding and documentation. You will coordinate audits, support HCC coding initiatives, and educate providers on CMS and NCQA standards to improve member care and program performance.

Requirements include an RN or LPN license or healthcare-related bachelor's degree, 3+ years in nursing or healthcare, and relevant coding certifications with a 4-month internal deadline for those not yet held.

Qualifications

• Current RN or LPN license or healthcare-related bachelor's degree.
• 6 years of experience with HEDIS/Quality abstraction or related field.
• 3 years of nursing or healthcare-related field.
• CPC, CRC, RHIA, RHIT, or CCS certification or must obtain within 4 months upon hire.
• Proficient with MS Office and data analysis.
• Strong communication and analytical skills.

Responsibilities

• Develop and manage process improvement initiatives with data analysis and report generation.
• Improve documentation and coding for CMS/ICD-10-CM coding and STARS goals.
• Monitor regulatory changes and adjust the compliance plan accordingly.
• Conduct audits (retrospective, concurrent, prospective) and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.
• Coordinate additional reviews and credentialing activities as requested.

Skills

TQM concepts

Statistics knowledge

Verbal & written communication

MS Office proficiency

Data analysis skills

Problem-solving

Education

RN/LPN license or healthcare degree

CPC/CRC/RHIA/RHIT/CCS cert

Tools

MS Access

Information systems

Job description

Highmark Health seeks a healthcare quality and compliance professional to lead process improvement across coding and documentation. You will coordinate audits, support HCC coding initiatives, and educate providers on CMS and NCQA standards to improve member care and program performance.

Requirements include an RN or LPN license or healthcare-related bachelor's degree, 3+ years in nursing or healthcare, and relevant coding certifications with a 4-month internal deadline for those not yet held.