RN Clinical Quality & Compliance Analyst

Highmark Health; Pennsylvania; Híbrido; USD 63.000 - 97.000; Jornada completa

Descripción de la vacante

Highmark Health is seeking aCompliance Specialist focused on quality improvement, coding accuracy, and regulatory adherence. The role collaborates with nursing staff, medical directors, and office personnel to improve documentation and coding accuracy, supporting CMS, NCQA standards and STARs metrics.

The position emphasizes data analysis, audits, education, and continuous process improvement across multiple departments; travel up to 25% is possible in a variety of care settings.

Formación

• RN or LPN license or healthcare-related bachelor's degree required.
• Substitutions: 6 years of experience with HEDIS/Quality abstraction, HCC Coding, or healthcare-related field in lieu of bachelor's degree.
• Preferred RN with an active compact license.

Responsabilidades

• Develop and manage process improvement initiatives with data analysis, reporting, documentation, and HCC coding.
• Analyze information from audits to improve care, documentation, and coding for members; assign ICD-10-CM codes for chronic conditions.
• Monitor regulatory and accrediting requirements and adjust the compliance plan to CMS guidelines.
• Conduct audits and communicate results; perform re-audits as needed.
• Educate providers on STARS, HEDIS, and HCC coding.
• Other duties as assigned.

Conocimientos

TQM concepts

Statistics

Verbal communication

Written communication

Interpersonal communication

Computer literacy

MS Office

Analytical skills

Problem solving

Travel ability

Educación

RN or LPN license

Bachelor’s degree in Healthcare field

Herramientas

Microsoft Office

Descripción del empleo

Highmark Health is seeking aCompliance Specialist focused on quality improvement, coding accuracy, and regulatory adherence. The role collaborates with nursing staff, medical directors, and office personnel to improve documentation and coding accuracy, supporting CMS, NCQA standards and STARs metrics.

The position emphasizes data analysis, audits, education, and continuous process improvement across multiple departments; travel up to 25% is possible in a variety of care settings.