Clinical Quality Management Analyst

Highmark Health

. Develop and manage process improvement initiatives for members and providers .

Posted 10/8/2026full-timeRemote • Pennsylvania • United StatesMid-LevelSenior💰 $62,700 - $97,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in HCC Coding, HEDIS Quality Abstraction, and process improvement initiatives within healthcare settings. Proficient in data analysis, compliance with CMS Coding Guidelines, and effective communication with medical professionals.

Highest-signal resume keywords

HCC CODINGHEDIS QUALITY ABSTRACTIONICD-10-CM CODINGCPC CERTIFICATIONANALYTICAL SKILLS

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisProcess ImprovementMedical Record DocumentationReport GenerationStatistical AnalysisQuality ImprovementCompliance PlanningAuditingCoding GuidelinesTotal Quality Management

Soft Skills

Excellent Communication SkillsProblem-Solving SkillsProfessional Manner

Tools & Technologies

Microsoft OfficeComparative DatabasesInformation Systems

Certifications & Qualifications

RN LicenseLPN LicenseCPC CertificationCRC CertificationRHIA CertificationRHIT CertificationCCS Certification

Industry Keywords

Value-Based CareAccreditationCMS Coding GuidelinesSTARSHEDISHealthcare ComplianceMedical AuditsCredentialing

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

Remote work arrangement
Travel requirement of 0%–25%