Clinical Quality Management Analyst

🔥 2 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $62.7k - $97.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Business Analyst

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Highmark Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1852

🛡️ Insurance

💼 Consulting

📦 Logistics

💰 $5M Grant on 2021-05

Insurance • Consulting • Logistics

Highmark Health is a healthcare company committed to reinventing the healthcare system and improving its services for everyone. The organization offers a broad range of career opportunities across various fields such as clinical care, technology, finance, and marketing. Highmark Health emphasizes diversity, equity, and inclusion in its workforce, creating a supportive environment for employees from all backgrounds. The company has been recognized for its commitment to disability inclusion, diversity, and military-friendly employment. As an independent licensee of the Blue Cross Blue Shield Association, Highmark Health strives to create remarkable healthcare experiences for its customers and employees alike.

📋 Description

• Develop and manage process improvement initiatives for members and providers • Perform detailed data analysis, process analysis, report generation, medical record documentation, and HCC coding • Conduct, collect, and analyze information and data from office site and medical record reviews • Improve care, services, documentation, and coding for members • Assign ICD-10-CM codes to chronic conditions • Coordinate with revenue, credentialing, and quality improvement programs to improve STARS and value-based care and maintain accreditation • Monitor changes in regulatory and accrediting body requirements • Adjust compliance plans to follow CMS Coding Guidelines • Conduct retrospective, concurrent, prospective, semi-annual, and annual audits • Identify gaps and communicate audit results • Conduct continuing education for providers on STARS, HEDIS, and HCC Coding • Conduct re-audits as needed • Coordinate credentialing, re-credentialing, member complaint investigations, Medical Director and facility site visit requests, reviews, audits, and accreditation activities as requested • Perform other duties as assigned or requested

🎯 Requirements

• 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 • 3 years of nursing or healthcare-related experience • Current State RN or LPN licensure or current 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 obtained within 4 months upon hire • Understanding of Total Quality Management concepts, techniques, process and outcome measurements • Understanding of statistics preferred for analyzing reports and validating study methodologies • Excellent verbal and written communication skills and professional manner • Ability to communicate with medical administrators, including Medical Directors and Physician Advisors • Computer literacy and knowledge of information systems and comparative databases • Working knowledge of Microsoft Office software, including Word, Excel, Access, and PowerPoint • Analytical and problem-solving skills with ability to understand and interpret clinical data • No language other than English required

🏖️ Benefits

• Remote work arrangement • Travel requirement of 0%–25%