Clinical Quality Management Analyst

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

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

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

Project Management

Statistics

Report Analysis

Study Methodology Validation

Benefits

Remote

Company

Integrated health insurance and care delivery organization

Pittsburgh, Pennsylvania, USA

https://www.highmarkhealth.org/hmk

Founded in 1848

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

Must be able to communicate with medical administrators, including Medical Directors and Physician Advisors related to problem identification, action plan implementation, ongoing monitoring, and problem resolution

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

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

Required skills

Represents the skills you have, click on the tags, HEDIS Quality Abstraction, HCC Coding, Medical Coding, Statistics, RN Licensure, LPN Licensure, Enhanced Nurse Licensure Compact (eNLC), CPC Certification, CRC Certification, RHIA Certification

Preferred skills

1 year of project management experience

Experience

3+ years