Quality Management Analyst — Medical Coding & Audits

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

Job summary

Highmark Inc. in Utah seeks a Healthcare Quality and Compliance professional to lead process improvement and coding accuracy across product lines.

The role collaborates with compliance, process improvement, and medical record teams to enhance documentation and align with CMS/NCQA standards. Responsibilities include conducting audits, provider education on STARS, HEDIS, and HCC Coding, and coordinating credentialing activities while ensuring timely improvements and adherence to HIPAA and privacy

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
• 3 years of nursing or healthcare-related field

Responsibilities

• Develop and manage process improvement initiatives with data analysis and reporting.
• Conduct office site visits and medical records reviews to improve documentation and coding.
• Coordinate credentialing, re-credentialing, and provider investigations as requested.
• Provide continuing education to providers on STARS, HEDIS, and HCC Coding.
• Monitor regulatory and accreditation requirements and adjust the compliance plan accordingly.
• Perform audits (retrospective, concurrent, prospective) and communicate results.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Medical admin comms

MS Office

Data analysis

Computer literacy

Education

RN or LPN license

Bachelor’s degree in Healthcare

Job description

Highmark Inc. in Utah seeks a Healthcare Quality and Compliance professional to lead process improvement and coding accuracy across product lines.

The role collaborates with compliance, process improvement, and medical record teams to enhance documentation and align with CMS/NCQA standards. Responsibilities include conducting audits, provider education on STARS, HEDIS, and HCC Coding, and coordinating credentialing activities while ensuring timely improvements and adherence to HIPAA and privacy