Clinical Quality & Process Improvement Analyst

Highmark Health; Sioux Falls (SD); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health is seeking a Quality Improvement professional with nursing credentials to enhance documentation, coding accuracy, and member outcomes across product lines. The role involves education on STARS/HEDIS/HCC, data-driven process improvement, and collaboration with compliance teams.

Requirements include RN/LPN license or healthcare degree, 3 years in healthcare, and certification in CPC/CRC/RHIA/RHIT/CCS or equivalent within 4 months of hire; some travel up to 25% may be expected.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a Healthcare-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.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, process analysis, and report generation.
• Conduct data collection and analysis from office/site reviews to improve care, documentation, and coding.
• Monitor regulatory/accrediting requirements and adjust the compliance plan to CMS guidelines.
• Conduct audits (retrospective, concurrent, prospective) and communicate results.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.
• Perform re-audits as needed.
• Other duties as assigned.

Skills

TQM concepts

Statistics

Verbal communication

MS Office

Analytical skills

Education

RN/LPN license

Healthcare BS/degree

CPC/CRC/RHIA/RHIT/CCS certs

Tools

MS Office

Job description

Highmark Health is seeking a Quality Improvement professional with nursing credentials to enhance documentation, coding accuracy, and member outcomes across product lines. The role involves education on STARS/HEDIS/HCC, data-driven process improvement, and collaboration with compliance teams.

Requirements include RN/LPN license or healthcare degree, 3 years in healthcare, and certification in CPC/CRC/RHIA/RHIT/CCS or equivalent within 4 months of hire; some travel up to 25% may be expected.