Clinical Validation Audit Quality Manager

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $75.1k - $123.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 2%

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EXL

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛡️ Insurance

📦 Logistics

💰 $2M Venture Round on 2015-01

Healthcare • Insurance • Logistics

EXL is a business consulting and services firm that focuses on leveraging data to enhance business operations and decision-making. With a strong emphasis on collaboration and adaptability, EXL partners with organizations to address their unique needs and culture while integrating data science and technology solutions. The company's areas of expertise include operations management, decision analytics, digital transformation, and various industries such as healthcare, finance, and insurance. EXL's mission is to help clients drive business evolution and maintain competitive advantage through tailored solutions and effective use of data.

📋 Description

• Lead planning, coordination, execution, and ongoing improvement of Clinical Validation Audit quality review programs • Manage day-to-day CVA quality review operations, including workflow distribution, inventory, QA aging, productivity, timeliness, client SLAs, quality expectations, and internal standards • Directly supervise CVA quality analysts through coaching, feedback, performance management, one-on-ones, training, development planning, and upskilling • Analyze audit accuracy, productivity, QA inventory, defect trends, root causes, auditor performance, documentation patterns, clinical validation outcomes, and quality metrics • Perform or oversee ATA audits and other assigned quality audits • Ensure RCA categories are appropriately marked and recurring trends receive follow-up, coaching, clarification, process correction, or escalation • Lead calibration sessions to promote consistent review decisions, rationale documentation, RCA selection, and application of clinical validation, coding, payer, and client guidance • Partner with Operations, Training, Technology, clients, and global partners to resolve quality and operational issues • Support program implementations by defining quality expectations, review criteria, sampling approaches, workflow needs, reporting requirements, and quality control processes • Identify responsible AI-in-the-workflow opportunities while maintaining human review, compliance, and data security • Monitor CMS, payer, clinical validation, coding, DRG, readmission, place of service, documentation, and related guideline updates • Escalate and help resolve client, quality, auditor performance, documentation, clinical validation, or operational issues • Support reporting on productivity, quality, audit accuracy, QA inventory, SLA performance, defect trends, RCA trends, and analyst performance metrics • Ensure consistency and alignment across quality analysts, programs, Operations, Training, Technology, clients, and global partners • Follow company Compliance, Information Security, and Regulatory policies and procedures

🎯 Requirements

• Registered Nurse, Associate’s or Bachelor’s degree required • 5+ years of acute care nursing experience • Prior experience leading teams or acting in a supervisory capacity • Strong analytical skills with ability to identify trends and support decision-making • CVA expertise, including evaluating clinical validation audit trends and identifying documentation or validation gaps • Ability to manage quality review workflows, team capacity, review inventory, productivity, calibration, and performance to meet quality and SLA targets • Strong attention to consistency, accuracy, and detail • Excellent interpersonal skills • Excellent verbal, written, and presentation communication skills • Ability to adapt to change and evolving program, client, and operational needs • Proficiency in Microsoft Office, dashboards, Excel, and audit/reporting systems • Knowledge of CMS regulations, payer requirements, quality governance, clinical validation, coding, DRG, readmission, and documentation guidelines • DRG retrospective overpayment identification auditing experience preferred • Readmission (PPR) auditing experience preferred • CCS, RHIA, or RHIT coding credentials preferred • Knowledge of Lean, Six Sigma, or equivalent process improvement methodologies preferred • A brief coding/auditing assessment may be included in the interview process

🏖️ Benefits

• Healthcare benefits • Vision benefits • Dental benefits • 401(k) options • Fast-paced, innovative environment with industry-leading experts • Hands-on experience with top-tier healthcare clients • Collaborative, supportive, and inclusive culture • 100% remote work • Limited travel may be required for team meetings

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