Highmark Health
Highmark Health
Highmark Health is a healthcare organization focused on improving how people experience and access care. Its work spans clinical services, technology, finance, marketing, and other functions that support the delivery of healthcare. As an independent licensee of the Blue Cross Blue Shield Association, the company brings together a broad range of professionals to help evolve the healthcare system. Highmark Health also highlights diversity, equity, and inclusion, with recognition for disability inclusion and military-friendly employment.

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.

Description

  • 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

Requirements

  • 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

Benefits

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

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