Remote Clinical Quality & Compliance Analyst

Highmark Health; Philadelphia (Philadelphia County); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health seeks a Compliance and Quality Improvement professional to collaborate across departments on documentation, coding accuracy, and adherence to CMS/NCQA standards. You will lead audits, provider education, and process-improvement initiatives to enhance care quality and program performance.

You will coordinate credentialing activities, perform site visits, and analyze data to drive STARS and value-based care improvements.

Qualifications

• Current RN or LPN license or healthcare-related Bachelor's degree required.
• 3 years of nursing or healthcare-related experience required.
• Licensure through eNLC, OCPC, CRC, RHIA, RHIT, or CCS preferred by some; must obtain within 4 months if not held.

Responsibilities

• Develop and manage process-improvement initiatives with data analysis and reporting.
• Conduct medical record reviews to improve documentation and ICD-10-CM coding.
• Coordinate credentialing, audits, and education on STARS, HEDIS, and QI processes.
• Communicate results and improvements to providers and leadership.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

MS Office

Analytical thinking

Education

RN/LPN license or Healthcare-related Bachelor's degree

Job description

Highmark Health seeks a Compliance and Quality Improvement professional to collaborate across departments on documentation, coding accuracy, and adherence to CMS/NCQA standards. You will lead audits, provider education, and process-improvement initiatives to enhance care quality and program performance.

You will coordinate credentialing activities, perform site visits, and analyze data to drive STARS and value-based care improvements.