Quality Management RN: Audits, Coding & Process Improvement

Highmark Health; Lincoln (NE); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a compliance and quality professional to partner with clinical and administrative teams in Lincoln, NE. The role focuses on improving documentation quality, coding accuracy for ICD-10-CM, and payer performance across product lines.

The candidate will lead process-improvement initiatives, conduct audits, educate providers on STARS, HEDIS, and HCC coding, and ensure adherence to CMS/NCQA standards while supporting accreditation efforts.

Qualifications

• Current state RN or LPN license or healthcare-related Bachelor's
• 3 years nursing or healthcare experience
• Certification in CPC/CRC/RHIA/RHIT/CCS or must obtain within 4 months of hire
• Ability to educate providers on STARS, HEDIS, and HCC coding
• Knowledge of CMS/NCQA standards and HIPAA compliance

Responsibilities

• Develop and manage process-improvement initiatives including data analysis, report generation, documentation, and HCC coding.
• Analyze site reviews to improve care, documentation, and ICD-10-CM coding; coordinate with revenue, credentialing and QA.
• Monitor regulatory and accrediting requirements; adjust the compliance plan per CMS Coding Guidelines.
• Audit processes and educate providers on STARS, HEDIS and HCC coding; perform re-audits.
• Other duties as assigned.

Skills

TQM concepts

Statistics knowledge

Verbal communication

Written communication

MS Office

Analytical skills

Education

RN/LPN license or Healthcare-related Bachelor's

Job description

Highmark Inc. is seeking a compliance and quality professional to partner with clinical and administrative teams in Lincoln, NE. The role focuses on improving documentation quality, coding accuracy for ICD-10-CM, and payer performance across product lines.

The candidate will lead process-improvement initiatives, conduct audits, educate providers on STARS, HEDIS, and HCC coding, and ensure adherence to CMS/NCQA standards while supporting accreditation efforts.