Clinical Quality Management Analyst

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Develop and oversee initiatives aimed at process improvement for both members and providers.

• Conduct thorough data analysis, process evaluation, report creation, medical record documentation, and HCC coding.

• Gather, assess, and analyze information and data from office site visits and medical record evaluations.

• Enhance care quality, services, documentation, and coding practices for members.

• Assign ICD-10-CM codes to chronic illnesses.

• Collaborate with revenue, credentialing, and quality improvement programs to enhance STARS ratings and value-based care, while ensuring compliance with accreditation standards.

• Keep abreast of changes in regulatory and accrediting body requirements.

• Modify compliance plans to adhere to CMS Coding Guidelines.

• Perform retrospective, concurrent, prospective, semi-annual, and annual audits.

• Identify deficiencies and communicate the findings of audits.

• Provide ongoing education for providers regarding STARS, HEDIS, and HCC Coding.

• Carry out re-audits as necessary.

• Coordinate credentialing, re-credentialing, member complaint investigations, Medical Director and facility site visit requests, reviews, audits, and accreditation tasks as needed.

• Perform additional responsibilities as assigned or requested.

⛳️ Requirements

• A current state RN or LPN license or a bachelor’s degree in a healthcare-related field.

• A minimum of 6 years of experience in HEDIS/Quality abstraction, HCC Coding/medical coding, or a healthcare-related field in place of a bachelor’s degree.

• At least 3 years of nursing or healthcare-related experience.

• Current State RN or LPN licensure or valid multi-state licensure through the enhanced Nurse Licensure Compact (eNLC), or certifications such as CPC, CRC, RHIA, RHIT, or CCS.

• Certifications like CPC, CRC, RHIA, RHIT, or CCS should be obtained within 4 months of hiring.

• A solid understanding of Total Quality Management concepts, techniques, and process and outcome measurements.

• Familiarity with statistics is preferred for analyzing reports and validating study methodologies.

• Exceptional verbal and written communication skills, along with a professional demeanor.

• Capability to communicate effectively with medical administrators, including Medical Directors and Physician Advisors.

• Proficient in computer usage and familiar with information systems and comparative databases.

• Competence in Microsoft Office applications, including Word, Excel, Access, and PowerPoint.

• Strong analytical and problem-solving abilities, with the capacity to comprehend and interpret clinical data.

• Proficiency in English is required; no other languages needed.

🏝️ Benefits

• Remote work option available.

• Travel requirement ranges from 0% to 25%.