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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, RN
Improve healthcare quality and compliance through clinical data analysis, medical record reviews, coding, audits, and accreditation work at Highmark Health. Support providers and quality initiatives with education and process improvement.
United States
Alabama
Alaska
Arizona
California
Colorado
Connecticut
Florida
Hawaii
Idaho
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming$62,700 – $97,200 / year
On-siteFull-timeMiddleSeniorEnglish RequiredBusiness AnalystDescription
- Partner with departments on compliance, process improvement, medical record reviews and coding, and member and provider satisfaction.
- Recommend and implement improvements to quality care, member services, and ICD-10-CM documentation.
- Advise and educate on medical record documentation, CMS and NCQA standards, and continuous quality improvement.
- Conduct special studies, audits, office site visits, and medical record reviews.
- Coordinate credentialing and re-credentialing, member complaint investigations, Medical Director and facility site visit requests, reviews, audits, and accreditation activities.
- Develop and oversee improvement initiatives using data and process analysis, report generation, medical record documentation, and HCC coding.
- Analyze office site and medical record review findings to improve care, services, documentation, coding, STARS, value-based care, credentialing, quality improvement, and accreditation.
- Track regulatory and accrediting-body changes and update compliance plans in line with CMS Coding Guidelines.
- Conduct retrospective, concurrent, prospective, semiannual, and annual audits; identify gaps and share results.
- Educate providers on STARS, HEDIS, and HCC coding.
- Conduct follow-up audits as needed.
- Complete other assigned or requested duties.
Requirements
- Current state RN or LPN license, or a bachelor's degree in a healthcare-related field.
- Six years of experience in HEDIS/quality abstraction, HCC or medical coding, or a healthcare-related field may substitute for a bachelor's degree.
- Three years of experience in nursing or a healthcare-related field.
- Current state RN or LPN license, multistate licensure through the enhanced Nurse Licensure Compact (eNLC), or CPC, CRC, RHIA, RHIT, or CCS certification; required certification or licensure must be obtained within four months of hire.
- Understanding of Total Quality Management (TQM) concepts, techniques, and process and outcome measures.
- Knowledge of statistics preferred for analyzing reports and validating study methods.
- Strong verbal and written communication skills and a professional manner.
- Ability to communicate with medical administrators, including Medical Directors and Physician Advisors, about identifying problems, implementing action plans, monitoring progress, and resolving issues.
- Computer literacy and familiarity with information systems and comparative databases.
- Working knowledge of Microsoft Office, including Word, Excel, Access, and PowerPoint.
- Analytical and problem-solving skills, including the ability to understand and interpret clinical data.
- Travel requirement of 0%–25%.
- Physical work site required.
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