Clinical Validation Audit Quality Manager

🔥 3 minutes ago

🇺🇸 United States – Remote

💵 $75.1k - $123.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 3%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 daily CVA quality review operations, including workflow distribution, inventory, QA aging, productivity, timeliness, client SLAs, and quality 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 and other quality audits, ensuring accurate and consistent audit determinations, clinical support, documentation, rationales, and outcomes • 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 issues and support CVA audit quality solutions • Support program implementations by defining quality expectations, review criteria, sampling approaches, workflows, 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, and documentation guideline updates • Escalate and help resolve client, quality, auditor performance, documentation, clinical validation, and operational issues • Support reporting on productivity, quality, audit accuracy, QA inventory, SLA performance, defect trends, RCA trends, and analyst performance • Ensure compliance with company Compliance, Information Security, and Regulatory policies

🎯 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 and ability to identify trends and support decision-making • Effective communication and interpersonal skills • Proficiency in Microsoft Office, dashboards, Excel, and audit/reporting systems • CVA expertise, including evaluating clinical validation audit trends and identifying documentation or validation gaps • Ability to manage quality review workflows, team capacity, inventory, productivity, calibration, and performance • Strong attention to consistency, accuracy, and detail • Ability to manage multiple priorities and projects under pressure • Ability to adapt to changing program, client, and operational needs • Knowledge of Lean, Six Sigma, or equivalent process improvement methodologies preferred • Prior clinical or coding validation audit experience preferred • Prior DRG retrospective overpayment identification auditing experience preferred • Prior readmission (PPR) auditing experience preferred • CCS, RHIA, or RHIT coding credentials preferred

🏖️ Benefits

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