[Hiring] Clinical Quality Management Analyst @Highmark Health

Role Description

This job works with appropriate departments in the areas of compliance, process improvement, medical record review and coding, and member and provider satisfaction for all product lines. Recommends and implements process improvements related to the potential of quality medical care and service to members and to improve documentation of these services for appropriate ICD 10-CM coding. Serves as a resource and educator regarding provider and office staff medical record documentation, federal and state standards including CMS and NCQA standards and continuous quality improvement principles. Perform special studies per audits, conducting office site visits and medical records reviews, ensuring improvement in performance for various initiatives in a timely manner. May coordinate credentialing, re-credentialing, member complaint investigations, Medical Director site visit requests, facility site visit requests, activities to include other reviews, audits, accreditation activities as requested on behalf of the organization.

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
• 1 year of project management experience (preferred)
• 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

Requirements

• An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements
• An understanding of statistics is also preferred to analyze various reports and validate study methodologies
• 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 databases
• 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

Benefits

• Pay Range Minimum: $62,700.00
• Pay Range Maximum: $97,200.00
• Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.

Company Description

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.