Healthcare Quality & Compliance Analyst

Highmark Health; Heber (UT); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health in Utah is seeking a Compliance and Quality Improvement specialist to drive process improvements across compliance, documentation, and coding. This role focuses on accurate ICD-10-CM coding, STARS, and HEDIS performance, with audits and education for providers and office staff.

You will conduct data analyses, support credentialing activities, and coordinate ongoing quality improvement initiatives to enhance member care and regulatory compliance.

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, or healthcare-related field in lieu of bachelor's degree
• 3 years of nursing or healthcare-related experience
• Experience with HEDIS, HCC coding, or quality audits preferred

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 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 understanding

Verbal communication

Written communication

MS Office

Data analysis

Education

RN/LPN license or healthcare bachelor's

Job description

Highmark Health in Utah is seeking a Compliance and Quality Improvement specialist to drive process improvements across compliance, documentation, and coding. This role focuses on accurate ICD-10-CM coding, STARS, and HEDIS performance, with audits and education for providers and office staff.

You will conduct data analyses, support credentialing activities, and coordinate ongoing quality improvement initiatives to enhance member care and regulatory compliance.