Healthcare Quality & Compliance Analyst

Highmark Health; Arkansas; 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 across all product lines.

You will drive documentation quality, correct ICD-10-CM coding, and support STARS and value-based care initiatives while coordinating credentialing and audits. The role requires RN/LPN or healthcare degree, nursing/healthcare experience, and knowledge of regulatory standards (CMS/NCQA).

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
• 1 year of project management experience
• Medicaid/Medicare experience
• Preferred experience with Managed Care Organizations

Responsibilities

• Develop and manage process-improvement initiatives using data analysis, reporting, and HCC coding for members and providers.
• Analyze office site and medical record data to improve care, documentation, and ICD-10-CM coding.
• Monitor CMS/Regulatory changes and adjust the compliance plan accordingly.
• Perform audits (retrospective, concurrent, prospective) and conduct provider education on STARS, HEDIS, and HCC.
• Other duties as assigned.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical skills

Problem-solving

ICD-10-CM coding

Education

RN or LPN license or Bachelor's degree in healthcare

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

3 years nursing or healthcare-related field

1 year project management experience

Medicaid/Medicare experience

Managed Care Organizations experience

Job description

Highmark Inc. is seeking a qualified professional to support compliance, process improvement, medical record review, and coding across all product lines.

You will drive documentation quality, correct ICD-10-CM coding, and support STARS and value-based care initiatives while coordinating credentialing and audits. The role requires RN/LPN or healthcare degree, nursing/healthcare experience, and knowledge of regulatory standards (CMS/NCQA).