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 (CVA) quality review programs.

• Manage the daily operations of CVA quality reviews, including workflow distribution, inventory management, quality assurance aging, productivity, timeliness, client service level agreements (SLAs), quality expectations, and adherence to internal standards.

• Directly supervise CVA quality analysts through coaching, providing feedback, performance management, conducting one-on-ones, training, development planning, and facilitating skill enhancement.

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

• Conduct or oversee ATA audits and other designated quality audits.

• Ensure that root cause analysis (RCA) categories are accurately assigned and that recurring trends are addressed with follow-up actions, coaching, clarifications, process adjustments, or escalations.

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

• Collaborate with Operations, Training, Technology, clients, and global partners to address quality and operational challenges.

• Assist in program implementations by establishing quality expectations, review criteria, sampling methods, workflow requirements, reporting needs, and quality control processes.

• Identify opportunities for responsible integration of AI in workflows while ensuring human review, compliance, and data security.

• Stay updated on guidelines from CMS, payers, clinical validation, coding, DRG, readmission, place of service, documentation, and related updates.

• Escalate and assist in resolving issues related to clients, quality, auditor performance, documentation, clinical validation, or operational matters.

• Support the reporting process for productivity, quality, audit accuracy, quality assurance inventory, SLA performance, defect trends, RCA trends, and performance metrics for analysts.

• Ensure consistency and alignment among quality analysts, programs, Operations, Training, Technology, clients, and global partners.

• Adhere to company Compliance, Information Security, and Regulatory policies and procedures.

⛳️ Requirements

• A Registered Nurse with an Associate’s or Bachelor’s degree is required.

• At least 5 years of experience in acute care nursing.

• Previous experience in leading teams or serving in a supervisory role.

• Strong analytical skills with the capacity to identify trends and aid in decision-making.

• Expertise in CVA, including assessing clinical validation audit trends and pinpointing documentation or validation deficiencies.

• Capability to manage quality review workflows, team workloads, review inventory, productivity, calibration, and performance to achieve quality and SLA objectives.

• High attention to detail, consistency, and accuracy.

• Exceptional interpersonal skills.

• Strong verbal, written, and presentation communication abilities.

• Flexibility to adapt to changes and evolving program, client, and operational needs.

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

• Familiarity with CMS regulations, payer requirements, quality governance, clinical validation, coding, DRG, readmission, and documentation guidelines.

• Preferred experience in DRG retrospective overpayment identification auditing.

• Preferred experience in readmission (PPR) auditing.

• Preferred coding credentials such as CCS, RHIA, or RHIT.

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

• A brief coding/auditing assessment may be part of the interview process.

🏝️ Benefits

• Comprehensive healthcare benefits.

• Vision benefits.

• Dental benefits.

• 401(k) options.

• A fast-paced, innovative environment featuring industry-leading experts.

• Hands-on experience with top-tier healthcare clients.

• A collaborative, supportive, and inclusive culture.

• Fully remote work opportunity.

• Limited travel may be necessary for team meetings.