Clinical Quality Consultant NP

About the role

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.

Responsibilities

• Focus on chart reviews by supplying clinical expertise to ensure full accurate and appropriate diagnosis, documentation, coding and care.
• 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.

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.

Qualifications

• Prefer AAPC Certified Risk Adjustment Coder

Benefits

Additional benefits include a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Pay

The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Schedule

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week.