Manager Clinical Performance & Quality (Nurse Practitioner/Physician Assistant)

Elevance Health•St. Louis, MO

12d•Hybrid

About The Position

This role is responsible for leading the quality documentation and value capture for all provider visit medical encounters to ensure application of accurate diagnosis codes (ICD-10 codes). The position requires the associate to be in the office 3x per week and within a commutable distance of an eligible office. The work hours are general business hours, Monday through Friday (8-5 central). This hybrid role fosters collaboration and connectivity while providing flexibility for productivity and work-life balance. The position combines structured office engagement with the autonomy of virtual work. Candidates not within a reasonable commuting distance will not be considered unless accommodation is granted. The role serves as the primary resource and subject matter expert on CMS Risk Adjustment and quality documentation. It involves developing and delivering clinical-focused training on advanced coding and documentation, incorporating coder feedback, and acting as a liaison to clinical leadership on value capture initiatives and high-quality clinical documentation. The role also includes developing performance management plans, KPIs, and clinical level tracking to meet quarterly goals for coding timeliness, accuracy, and Risk Adjustment. Additionally, it involves developing and managing clinical quality reviews, including peer review and clinical quality chart audits, targeting chart reviews, auditing percentages, score guidelines, feedback mechanisms, and ensuring compliance with remediation procedures. The role is also responsible for developing operational and clinical workflows for closing HEDIS care opportunities and participating in peer review of medical documentation. The manager hires, trains, coaches, counsels, and evaluates the performance of direct reports.

Requirements

Current, active, valid, and unrestricted nurse practitioner (NP) or PA license in applicable state(s) required.
Requires a master's in Nursing (or PA equivalent) and at least 3 years of clinical experience in applying appropriate diagnosis in the Medicare HCC Mode; or any combination of education and experience, which would provide an equivalent background.
Requires experience with CMS Risk Models.

Nice To Haves

Previous management/supervisory experience with direct reports.
HEDIS experience is preferred.
Experience with clinical data/documentation integrity is preferred (CDEO or CDEI).
Prefer AAPC Certified Risk Adjustment Coder (CRC) certification.

Responsibilities

Serves as the primary resource and subject matter expert on all CMS Risk Adjustment and quality documentation.
Develop and deliver clinical focused training on advance coding and documentation while incorporating coder feedback.
Liaison to the clinical leadership on alignment of goals and workflows to support value capture initiatives and high-quality clinical documentation.
Develop performance management plan, KPI's and clinical level tracking to meet quarterly goals for coding timeliness, accuracy, and Risk Adjustment.
Develop and manage clinical quality reviews to ensure peer review and clinical quality chart audit process including targeting chart reviews, auditing percentages, score guidelines feedback mechanism and ensure compliance with remediation procedures.
Develop operational and clinical workflows for closing HEDIS care opportunities to ensure practices and health plan success.
Participate in peer review of medical documentation for completed visits notes as well as patient profile information in EMR.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.