Anticipated End Date:
2026-08-28
Position Title:
Clinical Quality Consultant NP
Job Description:
Location: Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
Responsible for quality documentation, coding and value capture. How You'll Make a Difference:
Primary duties may include, but are not limited to: Focus on chart reviews by supplying clinical expertise to ensure full accurate and appropriate diagnosis, documentation, coding and care.
Will review all provider visit medical encounters and apply most appropriate diagnosis codes.
Overall accountability for the HCC/Risk Adjustment of goals and workflows to support value capture initiatives and high-quality clinical documentation.
Chart reviews for closing HEDIS care opportunities.
Liaison to coding team.
Chart reviews for closing HEDIS care opportunities to ensure practice and health plan success.
Participate in peer review of medical documentation for completed visit notes and patient profile information in EMR.
Reviews and corrects any ICD-10 codes that have been assigned in charts.
Provide feedback to the provider for improved documentation to support specific codes.
Minimum Requirements:
Requires an MS in Nursing and minimum of 3 years experience in applying appropriate diagnosis in the Medicare HCC model and/or CMS Risk Adjustment Model; or any combination of education and experience, which would provide an equivalent background.
Requires a current, active, valid and unrestricted RN license and NP license in applicable state(s).
Multi-state licensure is required if this individual is providing services in multiple states.
For Carelon Health, satisfactory completion of a Tuberculosis test is a requirement for this position.
Travels to worksite and other locations as necessary.
Preferred skills, qualifications and experiences:
Job Level:
Non-Management Exempt
Workshift:
1st Shift (United States of America)
Job Family:
MED > Licensed Nurse
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
