Clinical Quality & Process Improvement Analyst

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

Job summary

Highmark Inc. is seeking a senior professional to lead quality improvement efforts across compliance, process improvement, medical record review, and coding for all product lines.

You will drive improvements in documentation, ICD-10-CM coding, STARS, and value-based care while coordinating credentialing and audits. This role requires clinical licensure (RN/LPN) or a healthcare degree, plus relevant certifications.

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
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• Preferred Medicaid/Medicare experience; preferred experience with Managed Care Organizations

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 documentation and coding for members
• Monitor changes in regulatory/accrediting body requirements and adjust the compliance plan to CMS Coding Guidelines
• Conduct audits and education for 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

Computer literacy

MS Office

Education

RN or LPN license

Bachelor’s in healthcare

CPC/CRC/RHIA/RHIT/CCS certification

Tools

MS Office

Job description

Highmark Inc. is seeking a senior professional to lead quality improvement efforts across compliance, process improvement, medical record review, and coding for all product lines.

You will drive improvements in documentation, ICD-10-CM coding, STARS, and value-based care while coordinating credentialing and audits. This role requires clinical licensure (RN/LPN) or a healthcare degree, plus relevant certifications.