Clinical Validation Audit Quality Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the planning, coordination, execution, and continuous enhancement of Clinical Validation Audit quality review initiatives.

• Manage day-to-day CVA quality review operations, including the distribution of workflows, inventory management, QA aging, productivity monitoring, adherence to client SLAs, and maintenance of quality standards.

• Directly supervise CVA quality analysts, providing coaching, feedback, performance management, one-on-one sessions, training, development planning, and skills enhancement.

• Analyze metrics related to audit accuracy, productivity, QA inventory, defect trends, root causes, auditor performance, documentation patterns, clinical validation results, and overall quality metrics.

• Conduct or oversee ATA and other quality audits, ensuring precise and consistent audit determinations, clinical support, documentation, rationales, and outcomes.

• Facilitate calibration sessions to ensure uniform review decisions, rationale documentation, RCA selection, and the application of clinical validation, coding, payer, and client guidelines.

• Collaborate with Operations, Training, Technology, clients, and global partners to address issues and enhance CVA audit quality solutions.

• Assist in program implementations by establishing quality expectations, review criteria, sampling strategies, workflows, reporting requirements, and quality control measures.

• Identify opportunities for responsible AI integration into workflows while upholding human review, compliance, and data security standards.

• Stay informed on updates regarding CMS, payer regulations, clinical validation, coding, DRG, readmission, place of service, and documentation guidelines.

• Elevate and help resolve issues related to clients, quality, auditor performance, documentation, clinical validation, and operational challenges.

• Support productivity reporting, quality assessments, audit accuracy, QA inventory, SLA performance, defect and RCA trends, as well as analyst performance metrics.

• Ensure adherence to company Compliance, Information Security, and Regulatory policies.

⛳️ Requirements

• Must possess a Registered Nurse license, with either an Associate’s or Bachelor’s degree.

• A minimum of 5 years of experience in acute care nursing.

• Prior experience in leading teams or holding a supervisory role is required.

• Strong analytical abilities with a knack for identifying trends and facilitating decision-making.

• Excellent communication and interpersonal skills are essential.

• Proficient in Microsoft Office, dashboards, Excel, and audit/reporting systems.

• Expertise in CVA, including the evaluation of clinical validation audit trends and identification of documentation or validation discrepancies.

• Ability to manage quality review workflows, team capacity, inventory, productivity, calibration, and performance effectively.

• Keen attention to consistency, accuracy, and detail.

• Capable of managing multiple priorities and projects under pressure.

• Flexible and adaptable to changing program, client, and operational requirements.

• Knowledge of Lean, Six Sigma, or similar process improvement methodologies is preferred.

• Previous experience in clinical or coding validation auditing is preferred.

• Experience in DRG retrospective overpayment identification audits is preferred.

• Background in readmission (PPR) auditing is preferred.

• CCS, RHIA, or RHIT coding credentials are preferred.

🏝️ Benefits

• Comprehensive healthcare, vision, and dental benefits.

• 401(k) retirement options available.

• Dynamic, innovative work environment featuring industry-leading experts.

• Hands-on experience with premier healthcare industry clients.

• A collaborative, supportive, and inclusive workplace culture.

• Some travel may be required for team meetings.