Clinical Validation Director

Summary

Join our team as a Clinical Validation Director and lead a team of nurses and clinicians in performing clinical validation reviews. You will plan, direct, and oversee the clinical validation process, ensuring efficient and timely completion of claim reviews. Develop and implement policies and procedures, improve nurse performance, and maintain quality control measures. Collaborate with IT to enhance our proprietary system and serve as a subject matter expert for claim-related clinical questions. Interface with clients to market our clinical review programs. This role requires extensive experience in DRG clinical validation review and a strong understanding of clinical criteria and guidelines.

Requirements

• Current RN License and Registration in good standing
• Bachelor’s Degree
• Five years of Progressive Supervisor/Management experience in health care related organization
• Five to ten years of auditing experience specific to DRG clinical validation
• A minimum of five years’ experience working with ICD-9/10CM, MS-DRG, AP-DRG or any combination of education and experience that would an equivalent background
• Five to ten years’ experience of acute hospital experience preferably medical surgical
• Excellent written and verbal communication skills
• Detail-oriented, highly organized work skills
• Demonstrated initiative and perform as a motivated self-starter
• Excellent computer skills
• Experience analyzing and presenting data
• High speed internet (100 Mbps per person recommended) with secured WIFI
• A dedicated workspace with minimal interruptions to protect PHI and HIPAA information
• Must be able to sit and use a computer keyboard for extended periods of time

Responsibilities

• Coordinate the development of all policies and procedures pertaining to the DRG clinical validation review program to ensure compliance to all local, State, and Federal regulations and to meet the goals of the programs
• Communicate effectively with internal and external stakeholders to ensure alignment and successful claim outcomes
• Work collaboratively internally and externally to develop and implement innovative solutions and process improvements for the clinical team
• Serve as a subject matter expert for claim related questions
• Work collaboratively with IT to develop and improve workflows, automate solutions, and create additional technology enhancements
• Provide oversight of UAT testing to validate that system changes and enhancements are tested to ensure expected outcomes prior to implementation of these changes in the production environment for the clinical department
• Develop and implement a quality assurance program
• Ensure key metrics are met related to department quality and productivity
• Create auditing efficiencies to improve overall department productivity
• Foster a culture of continuing learning, collaboration, and employee development
• Ensure claim reviews follow client’s reimbursement policies, clinical criteria, and CMS guidelines
• Oversee and ensure timely completion of reviews to ensure contract compliance and regulatory timeframes are met

Preferred Qualifications

Master’s Degree preferred

Benefits

• Healthcare that fits your needs - We offer excellent medical, dental, and vision plan options that provide coverage to employees and dependents
• 401(k) with Employer Match - Join the team and we will invest in your future
• Generous Paid Time Off - Accrued PTO starting day one, plus additional days off when you’re not feeling well, to observe holidays
• Wellness - We care about your well-being. From Commuter Benefits to FSAs, we’ve got you covered
• Learning & Development - Through continued education/mentorship on the job and our investment in LinkedIn Learning, we’re focused on your growth as a working professional