Highmark Health Clinical Quality Management Analyst-5 in Pittsburgh, Pennsylvania



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.


  • 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 and 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.



  • Current state RN or LPN license or Bachelor’s degree in a Healthcare-related field


  • 6 years of progressive medical coding experience


  • None



  • 3-5 years of relevant, progressive experience in the area of specialization


  • None



  • CPC, CRC, RHIA, or CCS Certification


  • None


  • An understanding of Total Quality Management (TQM) concepts, techniques, process and outcome measurements ( 1-2 years)

  • An understanding of statistics is also preferred in order to analyze various reports and validate study methodologies (1-2 years)

  • 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. (1-2 years)

  • Demonstrated computer literacy and knowledge of information systems and comparative data bases. Working knowledge of Microsoft Office software (Word, Excel, Access, PowerPoint, etc.) (1-3 years)

  • Well-developed, analytical and problem solving skills with the ability to understand and interpret clinical data

  • Prior project management experience preferred (1-3 years)


Does this role supervise/manage other employees?



Is Travel Required?


Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.


Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity