Clinical Quality Management Analyst - RN (Remote)

Location: Work at home in Pennsylvania, United States; travel requirement is 0–25%, including office and site visits.

Company

hirify.global provides health insurance and healthcare services while supporting quality, compliance, and value-based care programs.

What you will do

• Develop and manage process improvement initiatives using data analysis, process analysis, reporting, medical record documentation, and HCC coding.
• Conduct office site and medical record reviews to improve care quality, service delivery, documentation, and ICD-10-CM coding.
• Coordinate with revenue, credentialing, and quality improvement programs to improve STARS, value-based care, and accreditation outcomes.
• Monitor CMS coding guidelines and other regulatory or accreditation requirements, updating compliance plans as needed.
• Conduct retrospective, concurrent, prospective, semi-annual, and annual audits; identify gaps, communicate results, and perform re-audits.
• Provide continuing education to providers on STARS, HEDIS, and HCC coding.

Requirements

• Current state RN or LPN license, an enhanced Nurse Licensure Compact license, or an accepted coding/healthcare certification is required.
• Bachelor’s degree in a healthcare-related field, or six years of relevant experience in HEDIS/quality abstraction, HCC coding, medical coding, or a healthcare-related field in lieu of the degree.
• At least three years of nursing or healthcare-related experience.
• Strong understanding of total quality management, clinical data analysis, process and outcome measurement, and problem-solving.
• Strong written and verbal communication skills, including communication with Medical Directors, physician advisors, administrators, and providers.
• Computer literacy and working knowledge of Microsoft Office, information systems, and comparative databases.

Nice to have

• Project management experience.
• Medicaid or Medicare experience.
• Experience with managed care organizations.
• RN status with an active compact license.
• Understanding of statistics for report analysis and study methodology validation.

Culture & Benefits

• Remote, work-at-home position based in Pennsylvania.
• Office-based work environment with occasional travel to work sites and offices.
• Work includes training and educating providers and office staff.
• Responsibilities require compliance with HIPAA, data security policies, federal and state regulations, and the company’s code of business conduct.