Clinical Quality & Process Improvement Analyst

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

Job summary

Highmark Inc. is seeking a qualified professional to support compliance, process improvement, medical record review and coding for all product lines. You will drive data analysis, documentation improvement and education on CMS, NCQA standards and quality initiatives.

The role includes audits and liaison with credentialing and quality programs. The candidate should hold an RN/LPN license or healthcare bachelor's degree, with 3 years in a healthcare field and experience in HEDIS/HCC coding;

Qualifications

• Current state RN or LPN license or Bachelor’s degree in a Healthcare-related field.
• 3 years of nursing or healthcare-related experience.
• 6 years of experience with HEDIS/Quality abstraction or HCC coding in lieu of a degree.
• CPC, CRC, RHIA, RHIT, or CCS certification (within 4 months of hire).

Responsibilities

• Develop and manage process improvement initiatives with data analysis, reporting and documentation, including HCC coding.
• Analyze data from office site or medical record reviews to improve care, documentation and coding for members.
• Monitor regulatory and accreditation changes and adjust the compliance plan to CMS 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

Total Quality Management (TQM)

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical skills

Problem solving

Education

RN or LPN license or Bachelor's degree in healthcare

6 years HEDIS/Quality abstraction or HCC coding experience in lieu of degree

CPC/CRC/RHIA/RHIT/CCS certification (within 4 months)

RN with active compact license

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a qualified professional to support compliance, process improvement, medical record review and coding for all product lines. You will drive data analysis, documentation improvement and education on CMS, NCQA standards and quality initiatives.

The role includes audits and liaison with credentialing and quality programs. The candidate should hold an RN/LPN license or healthcare bachelor's degree, with 3 years in a healthcare field and experience in HEDIS/HCC coding;