Quality Evaluator Senior (Nclex)

Elevance Health • San Juan, PR

8d • Hybrid

About The Position

Quality Evaluator Senior Location: Puerto Rico. This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. 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. Schedule: This position will work an 8-hour shift from 8:00 am - 5:00 pm (AST), Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs. Carelon Global Solutions (CGS), a fully owned subsidiary of Elevance Health, is a healthcare solutions company that is simplifying complex operational processes to improve the health of the healthcare system. Our Puerto Rico location operates a bilingual Spanish and English call center, providing clear and precise answers to customer queries. The Quality Evaluator Senior is responsible for supporting the site-specific HMC Quality programs by executing and evaluating the Quality Standard Operating Procedures (SOP), preparing trend reports and making process improvement recommendations to HMC Care Center Management. How You Will Make an Impact

Requirements

• Requires BA/BS in nursing, social work, respiratory therapy or related clinical field and minimum of 5 years of experience in managed care which includes progressive experience in clinical staff development and education, quality; or any combination of education and experience, which would provide an equivalent background.
• Current unrestricted license in applicable state(s) for designated field (i.e. RN, Social Work, Respiratory Therapy) required.
• Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level.

Nice To Haves

• Clinically relevant certification (i.e. Certified Diabetes Educator, Certified Case Manager) and a background in quality or performance improvement preferred.
• NCLEX Certification or current unrestricted RN license from one of the 50 states of the United States and current Puerto Rico Nursing Board license.
• Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.

Responsibilities

• Responsible for care center training and the preceptor program, conducting the quality calibration process and acts as a preceptor to new Quality Evaluators or Quality Evaluators in need of performance improvement.
• Develops and reports the Quality Evaluator performance scorecard results to Quality Director and Care Center Management.
• Assesses the content of scorecard results and develops work plan assignments for Care Center Management.
• Responsible for conducting random chart audits on assigned teams and providing management with a monthly report on the chart audits.
• May perform quality evaluations.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level