Clinical Quality Consultant NP

• 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.
  

• 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.
  

• Prefer AAPC Certified Risk Adjustment Coder
  

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.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

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. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact View email address on us.fitly.work for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act