Clinical Quality Management Analyst - RN (Remote)

Highmark Inc. is a healthcare organization seeking a Clinical Quality Management Analyst - RN to support compliance, process improvement, medical record review, coding, and member and provider satisfaction initiatives. The role analyzes clinical and operational data, conducts audits and site visits, educates providers, and supports quality, accreditation, credentialing, and regulatory compliance programs.

Responsibilities

Develop and manage process improvement initiatives from the Organization for member and providers to include detailed data analysis, process analysis, report generation, medical record documentation, and HCC Coding

Conduct, collect and analyze information and data from office site and/or medical record reviews to continually improve the care, services, proper documentation and coding for members, to properly assign ICD10-CM codes to chronic conditions, and coordination with the revenue programs, credentialing and quality improvement programs to improve STARS, value-based care and achieve and maintain accreditation

Monitor changes, corrections and clarifications in applicable regulatory/accrediting body requirements and make adjustments to the compliance plan to follow CMS Coding Guidelines

Conduct retrospective, concurrent, and prospective, semi-annual, and annual audits, identify gaps and communicate results. Conduct continuing education to providers on STARS, HEDIS, and HCC Coding. Conduct re-audits as needed

Other duties as assigned or requested

Preferred

1 year of project management experience

Medicaid/Medicare experience

Preferred experience with Managed Care Organizations

An understanding of statistics is also preferred to analyze various reports and validate study methodologies

RN with an active compact license

Project Management

Medicaid/Medicare Experience

Managed Care Organization Experience

Statistics

Report Analysis

Study Methodology Validation

Registered Nurse (RN)

Compact Nursing License

Company

Health insurance plans and benefits administration

Pittsburgh, Pennsylvania, USA

https://www.highmark.com/

Founded in 1996

10001+ employees

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

3 years of nursing or healthcare-related field

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 or must obtain within 4 months upon hire

An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements

Excellent verbal communication skills and professional manner, excellent written communication skills and a familiarity with a variety of writing styles

Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)

Well-developed, analytical and problem-solving skills with the ability to understand and interpret clinical data

1 year of project management experience

Medicaid/Medicare experience

Preferred experience with Managed Care Organizations

An understanding of statistics is also preferred to analyze various reports and validate study methodologies

RN with an active compact license

Required skills

Represents the skills you have, click on the tags, RN License, LPN License, CPC Certification, CRC Certification, RHIA Certification, RHIT Certification, HEDIS/Quality Abstraction, HCC Coding, Medical Coding, Statistics, Medicaid/Medicare Experience, Managed Care Organizations

Preferred skills

1 year of project management experience, Medicaid/Medicare experience, Preferred experience with Managed Care Organizations, RN with an active compact license, Glassdoor, 3.1, Health insurance plans and benefits administration., Pittsburgh, Pennsylvania, USA, https://www.highmark.com, Late Stage, Total Funding, $27.3M, 2018-04-06, Grant· $25M, 2014-08-07, Grant· $2.3M, Leadership Team, Keith Payet, President Government Business Segment, Recent News, Fierce Healthcare, 2026-10-11, 2026-10-08, Business Feed, Karen Hanlon named Highmark’s first female CEO, 2026-10-07, Company data provided by, AI Tools, Customize Your Resume, Maximize your interview chances

Experience

3+ years