RN Clinical Quality & Process Improvement Analyst

Highmark Health; Dover (DE); Remote; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a healthcare quality professional to collaborate with compliance, process improvement, medical record review, coding, and satisfaction teams across product lines.

Responsibilities include improving documentation for ICD-10-CM coding, educating providers, and coordinating credentialing-related activities to support accreditation and value-based care initiatives. The role emphasizes audits (retrospective and concurrent), education on STARS/HEDIS/HCC coding, and ensuring

Qualifications

• Current state 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.

Responsibilities

• Develop and manage process improvement initiatives with data analysis, process analysis, report generation, documentation, and HCC Coding.
• Conduct audits and site visits to improve care, documentation, coding, and STARS metrics.
• Monitor regulatory and accrediting changes and adjust the compliance plan accordingly.
• Conduct education for providers on STARS, HEDIS, and HCC Coding; perform re-audits as needed.
• Other duties as assigned or requested.

Skills

TQM concepts

Statistics

Verbal & written comms

Microsoft Office

Analytical problem-solving

Education

RN or LPN licensure OR Bachelor's in healthcare

Tools

MS Office

Job description

Highmark Inc. is seeking a healthcare quality professional to collaborate with compliance, process improvement, medical record review, coding, and satisfaction teams across product lines.

Responsibilities include improving documentation for ICD-10-CM coding, educating providers, and coordinating credentialing-related activities to support accreditation and value-based care initiatives. The role emphasizes audits (retrospective and concurrent), education on STARS/HEDIS/HCC coding, and ensuring