RN Clinical Quality & Coding Analyst — Process Improvement

Highmark Health; Atlanta (GA); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health in the United States seeks a Quality and Compliance Specialist to support compliance, process improvement, medical record review and coding across product lines. You will help ensure accurate ICD-10-CM coding and documentation while driving improvement initiatives.

The role involves audits, provider education on STARS, HEDIS, and HCC coding, and coordination with credentialing and quality programs to meet CMS/NCQA standards.

Qualifications

• Current state RN or LPN license or Bachelor's in a healthcare-related field.
• 3 years of nursing or healthcare-related field experience.
• CPC, CRC, RHIA, RHIT or CCS certification by hire or within 4 months.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, process analysis, report generation, medical record documentation, and HCC coding.
• Conduct and analyze information from site reviews to improve care, documentation and coding for members.
• Monitor regulatory/accrediting requirements and adjust the compliance plan to CMS guidelines.
• Perform audits, provide education to providers on STARS, HEDIS, and HCC coding; conduct re-audits as needed.
• Other duties as assigned.

Skills

TQM concepts

Statistics knowledge

Verbal communication

Written communication

Microsoft Office

Analytical thinking

Education

RN or LPN license or healthcare-related Bachelor's

CPC/CRC/RHIA/RHIT/CCS certification or must obtain within 4 months

Job description

Highmark Health in the United States seeks a Quality and Compliance Specialist to support compliance, process improvement, medical record review and coding across product lines. You will help ensure accurate ICD-10-CM coding and documentation while driving improvement initiatives.

The role involves audits, provider education on STARS, HEDIS, and HCC coding, and coordination with credentialing and quality programs to meet CMS/NCQA standards.