Clinical Validation Director

We are seeking a Clinical Validation Director with extensive experience in DRG clinical validation review. The Clinical Validation Director will plan, direct, coordinate and oversee the nurses and clinicians performing clinical validation reviews. The Clinical Validation Director will also assist in developing and growing the nurse/clinician clinical validation review team and implement policies and procedures to ensure claim reviews are completed in an efficient and timely manner. The individual selected for this role will assist in developing strategies to improve nurse performance across the team, develop and maintain quality control measures, assist with the implementation of new and innovative clinical concepts, and will work collaboratively with IT to develop technology enhancements to our proprietary system to improve clinical review workflows. This individual will serve as a subject matter expert for claim-related clinical questions, and interface with clients when needed to market the organization’s clinical review programs offered. This role requires knowledge and experience in applying guidelines and clinical criteria to clinical evaluations utilizing inpatient DRG concepts, national or client guidelines, peer review literature, and evidence based clinical decision support resources such as Up-to-date.

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.