Highmark Health
Highmark Health
Highmark Health एक स्वास्थ्य सेवा संगठन है, जिसका ध्यान लोगों के लिए स्वास्थ्य सेवाओं के अनुभव और उन तक पहुंच को बेहतर बनाने पर है। इसका कार्य नैदानिक सेवाओं, प्रौद्योगिकी, वित्त, विपणन और स्वास्थ्य सेवाओं के वितरण में सहायक अन्य कार्यों तक फैला हुआ है। Blue Cross Blue Shield Association के एक स्वतंत्र लाइसेंसधारी के रूप में, कंपनी स्वास्थ्य सेवा प्रणाली को विकसित करने में सहायता करने के लिए विभिन्न क्षेत्रों के पेशेवरों को साथ लाती है। Highmark Health विविधता, समानता और समावेशन को भी महत्व देती है तथा दिव्यांग समावेशन और सैन्य-अनुकूल रोजगार के लिए मान्यता प्राप्त कर चुकी है।

Clinical Quality Management Analyst - Pennsylvania Remote

Clinical Quality Management Analyst responsible for healthcare quality improvement, medical coding, audits, and accreditation activities. Supports Highmark Health members, providers, and value-based care programs.

विवरण

  • Lead process improvement initiatives serving members and providers
  • Analyze data and processes, prepare reports, document medical records, and perform HCC coding
  • Gather and evaluate information from office-site and medical-record reviews
  • Enhance member care, services, documentation, and coding practices
  • Assign ICD-10-CM codes to chronic conditions
  • Partner with revenue, credentialing, and quality improvement teams to strengthen STARS and value-based care programs and support accreditation
  • Track updates from regulatory and accrediting organizations
  • Revise compliance plans to align with CMS Coding Guidelines
  • Perform retrospective, concurrent, prospective, semi-annual, and annual audits
  • Recognize performance gaps and communicate audit findings
  • Provide ongoing provider education on STARS, HEDIS, and HCC coding
  • Complete re-audits when required
  • Coordinate credentialing and re-credentialing, member complaint investigations, Medical Director and facility site-visit requests, reviews, audits, and accreditation activities as assigned
  • Handle additional duties as assigned or requested

आवश्यकताएँ

  • An active state RN or LPN license, or a bachelor's degree in a healthcare-related field
  • Six years of experience in HEDIS or quality abstraction, HCC or medical coding, or a healthcare-related field may substitute for a bachelor's degree
  • Three years of nursing or healthcare-related experience
  • Active state RN or LPN licensure, multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), or CPC, CRC, RHIA, RHIT, or CCS certification
  • CPC, CRC, RHIA, RHIT, or CCS certification may be earned within four months of hire
  • Knowledge of Total Quality Management principles, methods, and process and outcome measurement
  • Statistics knowledge preferred for report analysis and study-methodology validation
  • Strong verbal and written communication skills with a professional approach
  • Ability to communicate effectively with medical administrators, including Medical Directors and Physician Advisors
  • Computer proficiency and familiarity with information systems and comparative databases
  • Working knowledge of Microsoft Office, including Word, Excel, Access, and PowerPoint
  • Strong analytical and problem-solving abilities, including the ability to interpret clinical data
  • English is the only required language

लाभ

  • Remote work arrangement
  • Travel expectation of 0% to 25%

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