Quality & Compliance Analyst: Process Improvement & Coding

Highmark Health; Orangeburg (SC); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health seeks a quality improvement professional to collaborate with compliance, process improvement, medical record review and coding across product lines.

You will lead data analyses, audits, and provider education to improve documentation and ICD-10-CM coding, while coordinating with credentialing and quality programs to enhance STARS and value-based care. Strong communication and project skills are essential.

Qualifications

• Current state RN or LPN license or Bachelor’s degree in a Healthcare-related field.
• Substitutions: 6 years of HEDIS/Quality abstraction, HCC Coding, or healthcare field in lieu of bachelor’s degree.
• Required: ~3 years nursing or healthcare-related field.
• Preferred: experience with Managed Care Organizations and Medicaid/Medicare.
• Licenses/certifications include active RN/LPN license or eligible compact/certifications and must obtain within 4 months.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, reporting, and accurate documentation and coding.
• Conduct and analyze office site reviews to improve care, services, and ICD10-CM coding accuracy.
• Educate providers on STARS, HEDIS, and HCC coding; perform audits and re-audits as needed.
• Coordinate credentialing activities and respond to provider-derived inquiries.

Skills

TQM concepts

Statistics understanding

Verbal communication

Written communication

Computer literacy

MS Office

Data interpretation

Education

RN or LPN license or healthcare-related bachelor's

Certifications: eNLC, CPC, CRC, RHIA, RHIT, CCS

Tools

Microsoft Office

Job description

Highmark Health seeks a quality improvement professional to collaborate with compliance, process improvement, medical record review and coding across product lines.

You will lead data analyses, audits, and provider education to improve documentation and ICD-10-CM coding, while coordinating with credentialing and quality programs to enhance STARS and value-based care. Strong communication and project skills are essential.