RN Clinical Quality & HEDIS Improvement Analyst

Highmark Health; Topeka (KS); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Health is seeking a Quality Improvement Specialist to collaborate with compliance, process improvement, medical record review and coding teams to enhance ICD-10-CM coding accuracy and documentation for all product lines.

The role emphasizes data analysis, audits, provider education on STARS, HEDIS and HCC coding, and driving performance improvements while ensuring regulatory compliance and accreditation readiness.

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
• CPC, CRC, RHIA, RHIT, or CCS Certification or must obtain within 4 months upon hire
• Preferred: Medicaid/Medicare experience and Managed Care Organizations exposure

Responsibilities

• Develop and manage process improvement initiatives from the Organization for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding.
• Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and achieve and maintain accreditation.
• Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan to follow CMS Coding Guidelines.
• Conduct retrospective, concurrent, and prospective, semi-annual, and annual audits, identify gaps and communicate results. Conduct continuing education to providers on STARS, HEDIS, and HCC Coding. Conduct re-audits as needed
• Other duties as assigned or requested.

Skills

TQM concepts

Statistics

Verbal communication

Written communication

Microsoft Office

Analytical thinking

Education

Bachelor's degree in a healthcare-related field

RN or LPN licensure or eNLC multi-state licensure

Job description

Highmark Health is seeking a Quality Improvement Specialist to collaborate with compliance, process improvement, medical record review and coding teams to enhance ICD-10-CM coding accuracy and documentation for all product lines.

The role emphasizes data analysis, audits, provider education on STARS, HEDIS and HCC coding, and driving performance improvements while ensuring regulatory compliance and accreditation readiness.