Clinical Quality Consultant - Nurse Practitioner - Remote

About the position For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. The Clinical Quality Consultant, as part of the National Clinical Quality Team (CQT), plays a vital role in monitoring and evaluating Home & Community Care Delivery (H&CCD) performance to ensure the delivery of high-quality care and services to beneficiaries. This includes assessing the appropriateness of care, clinical outcomes, and performance against regulatory, compliance, and customer requirements. The consultant leads and supports quality and performance improvement initiatives, conducts thorough documentation reviews, and provides expert guidance on program requirements such as CMS SNP Model of Care protocols, NCQA standards, and internal policies. Through cross-functional collaboration and strategic project involvement, the role helps drive continuous improvement, regulatory alignment, and a culture of clinical excellence across the organization. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Responsibilities

• Represent the Clinical Quality team during internal and external audit meetings
• Conducting reviews of peer-to-peer documentation to ensure adherence to all applicable standards, with a focus on promoting clinical excellence by enhancing documentation quality, enforcing policy compliance, and highlighting APC contributions through a streamlined and efficient review process
• Provide guidance and support to staff, promoting a culture of quality, compliance, and continuous improvement
• Serve as a Subject Matter Expert on program requirements for example: CMS SNP Model of Care protocols, evidence-based medical guidelines, NCQA standards, and internal policies and procedures
• Assist with the preparation of reports and maintenance of records related to work functions and projects
• Coordinate and support quality management programs and activities as needed
• Lead and/or support quality improvement projects based on identified opportunities, providing strategic guidance on regulatory, customer, performance, and contractual impacts
• Collaborate with internal business partners to drive quality improvement initiatives and represent the Clinical Quality Team in cross-functional efforts
• Participate in or coordinate departmental projects to support broader organizational goals
• Provide guidance on documentation standards, policies and procedures (P&Ps), job aids (JAs), audit tools, and training materials
• Recommend enhancements to internal systems and reporting tools to support overall clinical quality performance

Requirements

• Clinical Advanced Practice Clinician (NP/PA) or above with current, unrestricted license in state of residence
• 5+ years of clinical experience with proficiency in managing members with complex needs within various care models across diverse patient populations
• 3+ years working in managed care or in the insurance industry
• 1+ years of experience with Medicare and/or Medicaid
• Comprehensive knowledge of clinical standards of care, preventive health standards, HEDIS, NCQA, and regulatory agency requirements
• Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint, and Smartsheet
• Demonstrated ability to lead with strategic direction as well as develop tactical plans, drive performance and achieve targets
• Proven solid organizational skills, self-motivated and ability to interact with company staff at all levels
• Proven ability to develop and present formal presentations in various settings including senior leaders

Nice-to-haves

• 1+ years of clinical quality and documentation review experience
• Experience leading large scale projects within a highly matrixed organization

Benefits

• a comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution

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