Clinical Quality & Process Improvement Analyst

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

Job summary

Highmark Inc. seeks an experienced professional to advance quality improvement initiatives across compliance, process improvement, medical record review, and coding for all product lines.

The role focuses on accurate ICD-10-CM coding, STARS, HEDIS, and continuous improvement, coordinating credentialing and related audits. Responsibilities include data analysis, provider education, site visits, and audits to drive documentation quality and coding accuracy.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-related field
• 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
• 1 year of project management experience (preferred)
• Medicaid/Medicare experience (preferred)
• Managed Care Organization experience (preferred)
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire

Responsibilities

• Develop and manage process improvement initiatives with detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Analyze information from office/site reviews to improve care, documentation, coding, and alignment with STARS and value-based care.
• Monitor regulatory and accrediting requirements and adjust the compliance plan to CMS Coding Guidelines.
• Conduct audits (retrospective/concurrent/prospective) and educate providers on STARS, HEDIS, and HCC Coding; perform re-audits as needed.
• Other duties as assigned or requested.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical skills

Education

RN or LPN license OR Bachelor's degree in a Healthcare-related field

6 years of HEDIS/Quality abstraction or healthcare experience in lieu of bachelor's

Job description

Highmark Inc. seeks an experienced professional to advance quality improvement initiatives across compliance, process improvement, medical record review, and coding for all product lines.

The role focuses on accurate ICD-10-CM coding, STARS, HEDIS, and continuous improvement, coordinating credentialing and related audits. Responsibilities include data analysis, provider education, site visits, and audits to drive documentation quality and coding accuracy.