Nashville, Tennessee, United States · Remote OK
Anticipated End Date: 2026-08-28 Position Title: Clinical Quality Consultant NP Job Description: Location: Virtual: This role enables associates to work virtually full-time, except for required in-person training session…
Skills: Clinical quality, Chart review, Medical coding, HCC risk adjustment, HEDIS
Lake Mary, Florida, United States · Hybrid
$243k–$365k/yr
Anticipated End Date: 2026-08-12 Position Title: Distinguished Engineer Job Description: Distinguished Engineer Locations: This role requires associates to be in-office 1-2 days per week, fostering collaboration and conn…
Skills: Artificial intelligence, Large language models, Distributed systems, Python, Java
Adel, Iowa, United States · Hybrid
Anticipated End Date: 2026-09-30 Position Title: LTSS Service Coordinator-Western Iowa Job Description: LTSS Service Coordinator The candidate must reside in one of the below locations. PolkIdaCherokeePottawattamieStoryA…
Skills: Service coordination, Person centered planning, Motivational interviewing, Care coordination, Case management
Columbus, Indiana, United States · Hybrid
Anticipated End Date: 2026-08-14 Position Title: LTSS Service Coordinator - RN Clinician (Jennings County, IN & Decatur County, IN) Job Description: LTSS Service Coordinator - RN Clinician The candidate should reside in …
Skills: Case management, Care planning, Clinical assessment, Chronic illness management, Care coordination
Quinte West, Ontario, Canada · Hybrid
$90k–$170k/yr
Anticipated End Date: 2026-08-28 Position Title: Actuarial Analyst III Job Description: Actuarial Analyst III Location: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connect…
Skills: Excel, SQL, SAS, Actuarial Analysis, Risk Contract Implementation
Hanover, Maryland, United States · Hybrid
$80k–$100k/yr
Anticipated End Date: 2026-08-21 Position Title: Behavioral Health Clinical Quality Audit Analyst Senior - Maryland Job Description: Behavioral Health Clinical Quality Audit Analyst Senior Location: The ideal candidate w…
Skills: Quality improvement, Behavioral health, Risk management, Utilization review, Managed care
Ashburn, Virginia, United States · Hybrid
$112k–$193k/yr
Anticipated End Date: 2026-08-14 Position Title: Info Security Advisor (US) Job Description: Info Security Advisor Location: Ashburn, VA Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, foster…
Skills: Information security, Network security, Access control, Incident response, Risk assessment
Akron, Ohio, United States · Hybrid
Anticipated End Date: 2026-08-21 Position Title: Hemophilia Account Executive- Paragon Healthcare – Ohio, Indiana, Illinois Job Description: Hemophilia Account Executive- Paragon Healthcare – Ohio, Indiana, Illinois Sale…
Skills: Sales, Relationship building, Territory management, Forecasting, Negotiation
Walnut Creek, California, United States · Remote OK
$39/hr–$56/hr
Anticipated End Date: 2026-08-21 Position Title: Wound Care Utilization Management RN Job Description: Wound Care Utilization Management RN Virtual: This role enables associates to work virtually full-time, except for re…
Skills: Utilization management, Wound care, Clinical documentation, Care planning, Home health services
Iselin, New Jersey, United States · Hybrid
$41/hr–$62/hr
Anticipated End Date: 2026-08-21 Position Title: LTSS Service Coordinator - RN Clinician (New Jersey) Job Description: LTSS Service Coordinator - RN Clinician The candidate should reside in the following counties: Hudson…
Skills: Case management, Clinical assessment, Care planning, Utilization management, Chronic illness management
Atlanta, Georgia, United States · Hybrid
$103k–$170k/yr
Anticipated End Date: 2026-08-14 Position Title: Scrum Master Senior - IT Development Job Description: Scrum Master Senior - IT Development Location- Illinois Hybrid : This role requires associates to be in-office 1 - 2 …
Skills: Scrum, Agile methodologies, Kanban, Jira, Jira Align
Ashburn, Virginia, United States · Hybrid
$84k–$144k/yr
Anticipated End Date: 2026-08-14 Position Title: Security Analyst III (US) Job Description: Security Analyst III Location: Ashburn, VA Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fosterin…
Skills: Information security, Network security, Vulnerability management, Cloud security, Risk identification
Cincinnati, Ohio, United States · Hybrid
$17/hr–$26/hr
Anticipated End Date: 2026-08-12 Position Title: Utilization Management Representative II Job Description: Utilization Management Representative II Location: This role enables associates to work virtually full-time, exce…
Skills: Utilization Management, Customer Service, Medical Terminology, Triage, Benefit Eligibility
Wallingford, Connecticut, United States · Hybrid
$24/hr–$41/hr
Anticipated End Date: 2026-09-01 Position Title: Referral & Resource Specialist Job Description: Referral & Resource Specialist Location: Candidates must reside in one of the following states to be considered : MASSACHUS…
Skills: Behavioral health, Crisis intervention, Safety screening, Assessment, Telephonic intervention
Durham, North Carolina, United States · Hybrid
Anticipated End Date: 2026-08-31 Position Title: Clinical Care Advisor IDD (Program Consultant) Job Description: Clinical Care Advisor IDD (Program Consultant) Location: State of North Carolina Field: This field-based ro…
Skills: Program management, Compliance management, Operations management, Data collection, Training coordination
Miami, Florida, United States · Hybrid
Anticipated End Date: 2026-08-21 Position Title: Program Administrator, Vendor Management Job Description: Program Administrator, Vendor Management Hybrid 1: This role requires associates to be in-office 1 - 2 days per w…
Skills: Program administration, Client facing programs, Project management, Vendor management, Microsoft excel
Denver, Colorado, United States · Remote OK
$79k–$131k/yr
Anticipated End Date: 2026-08-19 Position Title: Nurse Case Mgr II (US) Job Description: Telephonic Nurse Case Manager II Sign on Bonus: $2000. Anticipated Job Posting End Date: 08/19/2026. Location - Virtual: This role …
Skills: Case management, Care planning, Clinical assessment, Utilization management, Critical thinking
Garden Grove, California, United States · Hybrid
$22/hr–$33/hr
Anticipated End Date: 2026-08-12 Position Title: Pharmacy Technician II Job Description: Pharmacy Technician II Location: CA-Garden Grove, 7373 Lincoln Way, FL-LAKE MARY, 3200 LAKE EMMA RD, STE 1000, MO-ST. LOUIS, 100 S …
Skills: Pharmacy technician, Data entry, Prior authorization, Prescription adjudication, Administrative support
Indianapolis, Indiana, United States · Hybrid
Anticipated End Date: 2026-08-14 Position Title: LTSS Service Coordinator - RN Clinician (La Porte County, IN & Porter County, IN) Job Description: LTSS Service Coordinator - RN Clinician The candidate should reside in L…
Skills: Case management, Care planning, Clinical assessment, Chronic illness management, Utilization management
Woburn, Massachusetts, United States · Hybrid
$19/hr–$32/hr
Anticipated End Date: 2026-08-31 Position Title: Credentialing Associate Job Description: Credentialing Associate Hybrid: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and con…
Skills: Credentialing, Re-credentialing, Database management, Provider relations, Contracting
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The Clinical Quality Consultant is responsible for performing clinical chart reviews to ensure accurate diagnosis, documentation, and coding for risk adjustment and HEDIS care opportunities. They act as a liaison to the coding team and provide feedback to providers to improve clinical documentation quality.
Candidates must hold a Master of Science in Nursing and possess a current, active, and unrestricted RN and NP license. A minimum of 3 years of experience in the Medicare HCC model or CMS Risk Adjustment Model is required.
Location: Virtual: 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.
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.
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.
Minimum 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.
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.
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.
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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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.
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.
NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.
Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner. Our nearly 100,000 associates serve more than 118 million people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health. We believe that improving health for everyone is possible. It begins by redefining health, reimagining the health system, and strengthening our communities.
Offices: 220 Virginia Ave, Indianapolis, Indiana 46204, US
Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner. Our nearly 100,000 associates serve more than 118 million people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health. We believe that improving health for everyone is possible. It begins by redefining health, reimagining the health system, and strengthening our communities.
Offices: 220 Virginia Ave, Indianapolis, Indiana 46204, US
