Quality & Compliance Analyst - HEDIS, HCC & STARS

Highmark Health; Yorktown (VA); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. in the United States seeks a Quality and Compliance professional to collaborate with compliance, process improvement, medical record review and coding across all product lines.

You will drive documentation improvements and accurate ICD-10-CM coding, supporting audits and accreditation initiatives. The role requires RN/LPN license or healthcare degree, 3+ years in nursing or healthcare, and certification (CPC/CRC/RHIA/RHIT/CCS) or plan to obtain within four months.

Qualifications

• Current 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.
• 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 care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and 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 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

Verbal & written comms

Microsoft Office

Analytical/Problem-solving

Education

RN/LPN license or healthcare degree

6 years HEDIS/Quality abstraction or healthcare experience

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

Tools

Microsoft Office

HIPAA/compliance systems

Job description

Highmark Inc. in the United States seeks a Quality and Compliance professional to collaborate with compliance, process improvement, medical record review and coding across all product lines.

You will drive documentation improvements and accurate ICD-10-CM coding, supporting audits and accreditation initiatives. The role requires RN/LPN license or healthcare degree, 3+ years in nursing or healthcare, and certification (CPC/CRC/RHIA/RHIT/CCS) or plan to obtain within four months.