Clinical Quality Consultant NP

Elevance Health•Grand Prairie, TX

9d•Remote

About The Position

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. Responsible for quality documentation, coding and value capture.

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.

Nice To Haves

Prefer AAPC Certified Risk Adjustment Coder

Responsibilities

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.