Headquarters: United States
URL: https://fa-ewjt-saasfaprod1.fa.ocs.oraclecloud.com:443/hcmUI/CandidateExperience/
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.
Salary Range: $75,100 – $123,400, based on experience, skills, and qualifications.
Location: 100% Remote, U.S.-based.
Travel: Limited travel may be required for team meetings.
A brief coding/auditing assessment may be included as part of the interview process.
For more information on benefits and what we offer, please visit us at https://www.exlservice.com/us-careers-and-benefits
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.
Qualifications
Experience
- 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.
- Prefer candidate with prior DRG retrospective overpayment identification auditing experience.
- Prefer candidate with prior readmission (PPR) auditing experience.
- Preference given to candidates with CCS, RHIA, or RHIT coding credentials.
- 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.
Skills & Competencies
- Strong analytical skills with the ability to identify trends, evaluate quality and audit performance, and support decision-making.
- CVA expertise, including the ability to evaluate clinical validation audit trends, identify clinical documentation or validation gaps, and translate findings into coaching, calibration, and process improvement actions.
- 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 in quality review outcomes.
- Results-oriented approach with the ability to manage multiple priorities and projects under pressure.
- Excellent interpersonal skills with the ability to build positive relationships with coworkers, team members, clients, and stakeholders.
- Excellent verbal, written, and presentation communication skills.
- Ability to adapt to change and support evolving program, client, and operational needs.
- Proficiency with Microsoft Office, dashboards, Excel, and audit/reporting systems.
- Knowledge of process improvement methodologies, including Lean, Six Sigma, or equivalent, preferred.
Key Success Indicators
- High-quality, accurate, timely, and consistent quality review results across Clinical Validation Audit and assigned programs, including correct clinical validation outcomes, clinical support, documentation requirement application, and audit rationale quality.
- Strong trend analysis, identification of improvement opportunities, and implementation of solutions.
- Team development and depth of knowledge maintained and enhanced.
- Alignment of quality processes across programs and global teams.
- Achievement of quality KPIs, SLA expectations, calibration standards, and client satisfaction metrics.
- Operational efficiencies and scalable processes implemented successfully.
What We Offer
- A fast-paced, innovative environment with a team of industry-leading experts.
- Hands-on experience with top-tier clients in the healthcare industry.
- A strong culture of collaboration, support, and inclusivity.
- Competitive benefits package, including healthcare, vision, dental, and 401(k) options.
The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.
To apply: https://weworkremotely.com/remote-jobs/exl-clinical-validation-audit-quality-manager