Clinical Quality & Process Improvement Analyst

Highmark Health; Saint Paul (MN); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. in Minnesota seeks a healthcare quality and compliance professional to collaborate with compliance, process improvement, medical record review and coding teams to improve documentation and ICD-10-CM coding across all product lines. You will support member and provider satisfaction and drive accuracy in coding.

The role requires RN/LPN license or healthcare-related bachelor’s degree, with experience in HEDIS, HCC coding, and audits. Travel is 0–25% and duties are office-based.

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.

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.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical skills

Education

RN or LPN license

Healthcare-related Bachelor's degree

CPC/CRC/RHIA/RHIT/CCS Certification

Tools

CMS Guidelines

Job description

Highmark Inc. in Minnesota seeks a healthcare quality and compliance professional to collaborate with compliance, process improvement, medical record review and coding teams to improve documentation and ICD-10-CM coding across all product lines. You will support member and provider satisfaction and drive accuracy in coding.

The role requires RN/LPN license or healthcare-related bachelor’s degree, with experience in HEDIS, HCC coding, and audits. Travel is 0–25% and duties are office-based.