Clinical Quality Management Analyst – RN

Highmark Health

. Work with departments on compliance, process improvement, medical record review and coding, and member and provider satisfaction .

Posted 10/9/2026full-timeUnited StatesMid-LevelSenior💰 $62,700 - $97,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in HEDIS, HCC Coding, and medical record documentation while ensuring compliance with CMS and NCQA standards. Proficient in process improvement initiatives and data analysis to enhance quality care and member satisfaction.

Highest-signal resume keywords

HEDIS Quality AbstractionHCC CodingCurrent RN or LPN LicenseProcess Improvement InitiativesTotal Quality Management (TQM)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewICD-10-CM DocumentationData AnalysisQuality ImprovementStatistical Analysis

Soft Skills

Excellent Communication SkillsAnalytical Problem-Solving Skills

Tools & Technologies

Microsoft Office SuiteInformation SystemsComparative Databases

Certifications & Qualifications

CPCCRCRHIARHITCCS Certification

Industry Keywords

CMS Coding GuidelinesAccreditation ActivitiesMember ServicesContinuous Quality ImprovementValue-Based Care

About the role

Key responsibilities & impact

Work with departments on compliance, process improvement, medical record review and coding, and member and provider satisfaction
Recommend and implement process improvements related to quality medical care, member services, and ICD-10-CM documentation
Serve as a resource and educator on medical record documentation, CMS and NCQA standards, and continuous quality improvement principles
Perform special studies, audits, office site visits, and medical record reviews
Coordinate credentialing, re-credentialing, member complaint investigations, Medical Director and facility site visit requests, reviews, audits, and accreditation activities as requested
Develop and manage process improvement initiatives involving data analysis, process analysis, report generation, medical record documentation, and HCC coding
Collect and analyze information from office site and medical record reviews to improve care, services, documentation, coding, STARS, value-based care, credentialing, quality improvement, and accreditation
Monitor regulatory and accrediting-body changes and adjust the compliance plan according to CMS Coding Guidelines
Conduct retrospective, concurrent, prospective, semi-annual, and annual audits; identify gaps and communicate results
Provide continuing education to providers on STARS, HEDIS, and HCC coding
Conduct re-audits as needed
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 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
Understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements
Understanding of statistics preferred to analyze reports and validate study methodologies
Excellent verbal and written communication skills and professional manner
Ability to communicate with medical administrators, including Medical Directors and Physician Advisors, regarding problem identification, action plan implementation, ongoing monitoring, and problem resolution
Computer literacy and knowledge of information systems and comparative databases
Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.)
Analytical and problem-solving skills with the ability to understand and interpret clinical data
Travel requirement of 0%–25%
Physical work site required