Healthcare Quality & Coding Compliance Analyst

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

Job summary

Highmark Health is seeking a skilled quality improvement professional to collaborate with compliance, coding, and clinical teams to enhance documentation and coding integrity across product lines.

You will lead data-driven process improvements, conduct medical record reviews, and support HEDIS and STARS initiatives. This role emphasizes regulatory adherence and continuous performance improvement in a dynamic healthcare environment.

Qualifications

• Current state RN or LPN license or Bachelor's degree in a healthcare-related field.
• 6 years of experience with HEDIS/Quality abstraction or HCC coding or healthcare-related field in lieu of bachelor's.
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire.

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

Data analysis

Analytical skills

Problem solving

Communication

Medical record documentation

Education

RN/LPN license or bachelor's in healthcare

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

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

Tools

Microsoft Office

Job description

Highmark Health is seeking a skilled quality improvement professional to collaborate with compliance, coding, and clinical teams to enhance documentation and coding integrity across product lines.

You will lead data-driven process improvements, conduct medical record reviews, and support HEDIS and STARS initiatives. This role emphasizes regulatory adherence and continuous performance improvement in a dynamic healthcare environment.