Clinical Validation Audit Quality Manager

EXL•United States,

14h•$75,100 - $123,400•Remote

About The Position

The CVA Quality Manager leads the planning, coordination, and execution of Clinical Validation Audit quality review activities, ensuring quality teams meet productivity goals, inventory expectations, client SLAs, and internal quality standards. This role oversees inventory, QA aging, risks, and day-to-day quality performance, while collaborating cross-functionally to support program success. The role directly manages a team of CVA quality analysts responsible for reviewing auditor-completed Clinical Validation Audit work, validating audit accuracy, and ensuring accurate clinical validation outcomes. This leader may also oversee additional quality specialties within clinical or coding audit programs. The ideal candidate demonstrates strong leadership and analytical skills, along with expert clinical knowledge, experience with inpatient medical record review, clinical criteria documentation requirements, audit tools, and a solid understanding of CMS regulations, payer requirements, and quality governance.

Requirements

Registered Nurse, Associate’s or Bachelor’s degree required.
5+ years of acute care nursing experience with preference given to candidates with prior clinical or coding validation audit experience.
Prior experience leading teams or acting in a supervisory capacity, preferably overseeing CVA quality analysts or quality teams supporting clinical validation, clinical audit, or coding specialties.
Strong analytical skills with ability to identify trends and support decision-making.
Effective communication and interpersonal skills.
Proficiency in Microsoft Office and audit/reporting systems.

Nice To Haves

Prior DRG retrospective overpayment identification auditing experience.
Prior readmission (PPR) auditing experience.
Preference given to candidates with CCS, RHIA, or RHIT coding credentials.
Knowledge of process improvement methodologies, including Lean, Six Sigma, or equivalent, preferred.

Responsibilities

Actively drive the execution and ongoing improvement of Clinical Validation Audit quality review programs, including DRG validation, readmissions, place of service reviews, targeted reviews, provider- or concept-specific reviews, appeals, and other assigned CVA quality activities.
Manage day-to-day CVA quality review operations, including workflow distribution, inventory, QA aging, productivity, timeliness, client SLAs, quality expectations, and internal standards.
Provide direct supervision to CVA quality analysts and, as needed, quality analysts supporting other clinical or coding quality specialties through coaching, feedback, performance management, one-on-ones, training, development planning, and ongoing upskilling.
Analyze audit accuracy, productivity, QA inventory, defect trends, root cause analysis, auditor performance, documentation patterns, clinical validation outcomes, and quality performance metrics to take action that improves team performance and overall quality results.
Perform or oversee ATA audits and other assigned quality audits as part of the team’s CVA quality review activities, ensuring audit determinations, clinical support, documentation, rationales, and quality outcomes are accurate, consistent, and aligned with client and program expectations.
Ensure RCA categories are marked appropriately and that recurring trends result in timely follow-up, coaching, clarification, process correction, or escalation as needed.
Lead regular calibration with CVA quality analysts to promote consistent review decisions, aligned rationale documentation, appropriate RCA selection, and consistent application of clinical validation, coding, payer, and client guidance.
Partner with Operations, Training, Technology, clients, and global partners to drive consistency, resolve quality or operational issues, and support CVA audit quality solutions.
Support program implementations and operational initiatives by defining CVA quality expectations, review criteria, sampling approaches, workflow needs, reporting requirements, and quality control processes.
Identify responsible AI-in-the-workflow opportunities that improve audit quality, consistency, efficiency, trend identification, documentation support, and team productivity while maintaining appropriate human review, compliance, and data security expectations.
Monitor CMS, payer, clinical validation, coding, DRG, readmission, place of service, documentation, and related guideline updates to ensure quality reviews remain compliant and current.
Escalate and help resolve client, quality, auditor performance, documentation, clinical validation, or operational issues as needed.
Support reporting activities, including productivity, quality, audit accuracy, QA inventory, SLA performance, defect trends, RCA trends, and analyst performance metrics.
Ensure consistency and alignment across quality analysts, assigned programs, Operations, Training, Technology, clients, and global partners.
Conduct all job functions and responsibilities in accordance with all company Compliance, Information Security, and Regulatory policies, procedures, and programs.