Abrar Admin

Toney HealthCare Consulting, LLC

Job Summary The Utilization Management (UM) Trainer &amp; Auditor is responsible for developing, delivering, and evaluating training programs for UM staff while conducting ongoing audits to ensure compliance with regulatory, accreditation, and internal quality standards. This role supports clinical and non-clinical UM staff by promoting consistency, accuracy, regulatory adherence, and best practices in authorization review, documentation, and decision-making processes.The position serves as a subject matter expert in UM policies, NCQA standards, CMS guidelines, state/federal regulations, and health plan requirements.Key Responsibilities:Training &amp; Education<ul><li>Design, develop, and implement comprehensive onboarding and ongoing training programs for UM staff (RNs, LVNs, care coordinators, and non-clinical reviewers).</li><li>Create training materials, job aids, reference guides, and competency assessments.</li><li>Facilitate instructor-led, virtual, and self-paced training sessions.</li><li>Conduct new hire orientation specific to UM processes, systems, and regulatory requirements.</li><li>Provide remedial training and coaching based on audit findings and performance gaps.</li><li>Monitor and evaluate training effectiveness through testing, observation, and performance metrics.</li><li>Maintain training documentation and attendance records in compliance with accreditation standards.</li></ul>Auditing &amp; Quality Assurance<ul><li>Perform routine and targeted audits of UM cases, including prior authorizations, concurrent review, retrospective review, and appeals.</li><li>Evaluate documentation accuracy, timeliness, medical necessity determinations, and adherence to criteria (e.g., InterQual, MCG).</li><li>Assess compliance with NCQA, CMS, state regulations, and internal policies.</li><li>Identify trends, risk areas, and opportunities for process improvement.</li><li>Prepare detailed audit reports with findings, scoring, and corrective action recommendations.</li><li>Collaborate with leadership to implement corrective action plans and monitor improvement.</li><li>Support readiness and documentation for regulatory and accreditation audits.</li></ul>Compliance &amp; Process Improvement<ul><li>Serve as a resource for regulatory requirements impacting UM operations.</li><li>Participate in policy development and updates to ensure alignment with current regulations and best practices.</li><li>Analyze performance data (turnaround times, denial rates, audit scores) to identify training needs.</li><li>Partner with Clinical Leadership, Compliance, and Quality teams to support continuous improvement initiatives.</li></ul>Knowledge, Skills &amp; Abilities:<ul><li>Strong understanding of UM workflows including prior authorization, concurrent review, and appeals.</li><li>Knowledge of regulatory requirements and accreditation standards (NCQA preferred).</li><li>Excellent presentation and facilitation skills.</li><li>Strong analytical and critical-thinking abilities.</li><li>Ability to interpret clinical documentation and medical policy.</li><li>Excellent written and verbal communication skills.</li><li>Proficiency with UM systems and Microsoft Office applications.</li><li>Strong organizational skills and ability to manage multiple priorities.</li></ul>Qualifications:<ul><li>Bachelor&rsquo;s or Master&rsquo;s degree in Nursing, Healthcare Administration, Public Health, or related field required.</li><li>Clinical (active and unrestricted) licensure (e.g., RN) required.</li><li>5&ndash;10+ years of experience in a clinical setting.</li><li>5+ years of experience in health plan Utilization management.</li><li>2+ years of experience in training, auditing, quality assurance and/or education role.</li><li>Experience with healthcare technology (e.g., EHR systems like Epic or Cerner, clinical decision support).</li><li>Deep knowledge of healthcare regulations (e.g., CMS, HIPAA, Joint Commission) and clinical quality programs.</li><li>Strong analytical, communication, and stakeholder engagement skills.</li><li>Strong knowledge of NCQA standards, CMS guidelines, and state/federal regulations.</li><li>Experience with medical necessity criteria tools (InterQual, MCG, or similar).</li></ul>Preferred Qualifications:<ul><li>Prior audit experience within a managed care or health plan setting preferred.</li><li>Experience with value-based care models, ACOs, or population health strategies.</li><li>Certification in Lean Six Sigma, PMP, or healthcare quality (e.g., CPHQ).</li></ul>Pay: $75,962.00 - $100,000.00 per yearBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li><li>Work from home</li></ul>Experience:<ul><li>health plan UM: 5 years (Required)</li><li>training, auditing and quality assurance: 2 years (Required)</li></ul>License/Certification:<ul><li>RN License (Required)</li></ul>Work Location: Remote

Training & Auditor Clinical Consultant Nurse

Overview The Clinical Utilization Management (UM) Supervisor is responsible for overseeing daily operations of the Utilization Management team to ensure timely, accurate, and appropriate clinical decision-making and case management. This role provides leadership, coaching, and clinical oversight to UM staff including nurses and support personnel, ensuring compliance with regulatory requirements, accreditation standards, and organizational policies.Essential Functions/Key Responsibilities:<ul><li>Supervise daily activities of the UM team, including nurses and administrative support staff.</li><li>Ensure timely and accurate medical necessity reviews for inpatient, outpatient, and other healthcare services according to internal protocols and regulatory guidelines.</li><li>Monitor workloads, productivity, and performance metrics to ensure team efficiency and effectiveness.</li><li>Provide clinical oversight and guidance on complex cases and escalate when needed.</li><li>Ensure adherence to federal and state regulations, NCQA/URAC standards, and payer requirements.</li><li>Collaborate with medical directors, providers, and case management staff to coordinate appropriate care and avoid unnecessary utilization.</li><li>Participate in audits, reporting, and performance improvement initiatives.</li><li>Train, mentor, and evaluate staff performance; participate in hiring and disciplinary processes.</li><li>Develop and implement standard operating procedures (SOPs) for UM functions.</li><li>Stay updated on changes in healthcare regulations, utilization trends, and evidence-based clinical guidelines.</li></ul>Competencies:<ul><li>Leads by example, motivates others, and supervisors team dynamics effectively.</li><li>Thrives in fast paced, evolving environments and adjusts quickly to changing client needs.</li><li>Applies sound clinical reasoning to support decision making and guidance.</li><li>Builds trust with clients, anticipates their needs, and delivers high value outcomes.</li><li>Sets clear expectations, measures performance, and takes ownership of outcomes.</li><li>Works cross functionally with internal teams and client stakeholders to achieve aligned goals.</li><li>Anticipates challenges, investigates root causes and develops solutions.</li><li>Provides regular feedback and mentors team.</li><li>Champions operational efficiency.</li></ul>Required education and experience:<ul><li>Minimum 5 years of Utilization Management experience.</li><li>At least 2 years of leadership or team management in a UM setting.</li><li>Active, unrestricted RN license required</li><li>Strong understanding of InterQual and/or MCG criteria.</li><li>Experience managing remote clinical teams across multiple engagements</li><li>Familiarity with Medicare, Medicaid, and commercial payer UM requirements.</li><li>Excellent communication, data analysis, and problem-solving skills.</li></ul>Preferred education, certifications and/or experience:<ul><li>Bachelor&rsquo;s degree in Nursing (BSN)</li><li>Consulting or project-based experience preferred.</li></ul>Physical Requirements/Work environment:<ul><li>Remote role with occasional travel (Less than 5%)</li><li>Must have a home office, mobile phone, computer with security requirements met.</li><li>Prolonged periods of sitting at a desk and working on a computer.</li><li>Ability to speak, hear, and comprehend both written and verbal communications.</li></ul>Pay: $53,129.39 - $63,983.79 per yearBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Experience:<ul><li>leadership (UM setting): 2 years (Required)</li><li>Utilization management: 5 years (Required)</li></ul>License/Certification:<ul><li>RN License (Required)</li></ul>Work Location: Remote

Supervisor, Utilization Management

OverviewThe coordinator &mdash; Physician Review Operations &amp; Training serves as a key operational liaison supporting physician review activities and ensuring consistent adherence to system workflows, training standards, and performance expectations. This role functions as the trainer, supporting physician reviewers through onboarding, ongoing education, scheduling coordination, and performance monitoring. The coordinator works closely with both internal stakeholders and Customer partners to ensure efficient operations, compliance with established processes, and successful execution of physician review programs.Key ResponsibilitiesTraining &amp; System Support<ul><li>Serve as the trainer, providing onboarding and ongoing training to physician reviewers on system functionality, workflows, and documentation requirements.</li><li>Support adoption of system updates, workflow changes, and best practices through structured training and coaching.</li><li>Monitor completion of Customer-assigned training requirements and follow up to ensure compliance.</li><li>Act as a primary point of contact for physician reviewers regarding system functionality and process questions.</li></ul>Operational Coordination<ul><li>Support scheduling coordination for physician review activities to ensure adequate coverage and timely completion of assigned work.</li><li>Coordinate with Customer stakeholders and internal leadership regarding operational or performance-related matters.</li><li>Assist in managing communication between physician reviewers, Customer representatives, and Company leadership.</li></ul>Documentation &amp; Compliance Oversight<ul><li>Perform documentation reviews to ensure physician reviews meet required quality standards and adhere to established system workflows and processes.</li><li>Monitor system process adherence and identify opportunities for improvement or additional training.</li><li>Escalate compliance or workflow concerns as appropriate.</li></ul>Performance Monitoring &amp; Reporting<ul><li>Review physician performance reports provided by the Customer or available within Customer systems.</li><li>Track performance trends and support leadership in identifying coaching or corrective action opportunities.</li><li>Assist with performance improvement initiatives as needed.</li></ul>User Access &amp; IT Coordination<ul><li>Coordinate new user system access setup with Customer IT teams.</li><li>Manage deactivation of system access when required to ensure security and compliance standards are maintained.</li></ul>Knowledge, Skills &amp; Abilities:<ul><li>Strong understanding of UM workflows including prior authorization, concurrent review, and appeals.</li><li>Knowledge of regulatory requirements and accreditation standards (NCQA preferred).</li><li>Excellent presentation and facilitation skills.</li><li>Strong analytical and critical-thinking abilities.</li><li>Ability to interpret clinical documentation and medical policy.</li><li>Excellent written and verbal communication skills.</li><li>Proficiency with UM systems and Microsoft Office applications.</li><li>Strong organizational skills and ability to manage multiple priorities.</li></ul>Qualifications:<ul><li>Bachelor&rsquo;s or Master&rsquo;s degree in Nursing, Healthcare Administration, Public Health, or related field required.</li><li>Clinical (active and unrestricted) licensure (e.g., RN) required.</li><li>5&ndash;10+ years of experience in a clinical setting.</li><li>5+ years of experience in health plan Utilization management.</li><li>2+ years of experience in training, auditing, quality assurance and/or education role.</li><li>Experience with healthcare technology (e.g., EHR systems like Epic or Cerner, clinical decision support).</li><li>Deep knowledge of healthcare regulations (e.g., CMS, HIPAA, Joint Commission) and clinical quality programs.</li><li>Strong analytical, communication, and stakeholder engagement skills.</li><li>Strong knowledge of NCQA standards, CMS guidelines, and state/federal regulations.</li><li>Experience with medical necessity criteria tools (InterQual, MCG, or similar).</li></ul>Preferred Qualifications:<ul><li>Prior audit experience within a managed care or health plan setting preferred.</li><li>Experience with value-based care models, ACOs, or population health strategies.</li><li>Certification in Lean Six Sigma, PMP, or healthcare quality (e.g., CPHQ).</li></ul>Core Competencies<ul><li>Training and facilitation skills</li><li>Attention to detail and compliance focus</li><li>Stakeholder collaboration</li><li>Process improvement mindset</li><li>Strong organizational and follow-through abilities</li></ul>Pay: $60,534.39 - $72,901.63 per yearExperience:<ul><li>Utilization management: 5 years (Preferred)</li><li>training: 2 years (Required)</li><li>auditing: 2 years (Required)</li></ul>License/Certification:<ul><li>RN License (Required)</li></ul>Work Location: Remote

Physician Review Operations & Training

Join Toney HealthCare Consulting, LLC and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Toney HealthCare Consulting, LLC

About Company

Training & Auditor Clinical Consultant Nurse

Supervisor, Utilization Management

Physician Review Operations & Training