Quality Evaluator Senior (Nclex)

Anticipated End Date:

2026-04-12

Position Title:

Quality Evaluator Senior (Nclex)

Job Description:

​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

Primary duties may include, but are not limited to:

• 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.

Minimum 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.

Preferred Skills, Capabilities, and Experiences:

• 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.

• Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed/Certified - Other

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.

Who We Are

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.

How We Work

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 str