Training & Auditor Clinical Consultant Nurse

Job Summary
The Utilization Management (UM) Trainer & 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 & Education

• Design, develop, and implement comprehensive onboarding and ongoing training programs for UM staff (RNs, LVNs, care coordinators, and non-clinical reviewers).
• Create training materials, job aids, reference guides, and competency assessments.
• Facilitate instructor-led, virtual, and self-paced training sessions.
• Conduct new hire orientation specific to UM processes, systems, and regulatory requirements.
• Provide remedial training and coaching based on audit findings and performance gaps.
• Monitor and evaluate training effectiveness through testing, observation, and performance metrics.
• Maintain training documentation and attendance records in compliance with accreditation standards.

Auditing & Quality Assurance

• Perform routine and targeted audits of UM cases, including prior authorizations, concurrent review, retrospective review, and appeals.
• Evaluate documentation accuracy, timeliness, medical necessity determinations, and adherence to criteria (e.g., InterQual, MCG).
• Assess compliance with NCQA, CMS, state regulations, and internal policies.
• Identify trends, risk areas, and opportunities for process improvement.
• Prepare detailed audit reports with findings, scoring, and corrective action recommendations.
• Collaborate with leadership to implement corrective action plans and monitor improvement.
• Support readiness and documentation for regulatory and accreditation audits.

Compliance & Process Improvement

• Serve as a resource for regulatory requirements impacting UM operations.
• Participate in policy development and updates to ensure alignment with current regulations and best practices.
• Analyze performance data (turnaround times, denial rates, audit scores) to identify training needs.
• Partner with Clinical Leadership, Compliance, and Quality teams to support continuous improvement initiatives.

Knowledge, Skills & Abilities:

• Strong understanding of UM workflows including prior authorization, concurrent review, and appeals.
• Knowledge of regulatory requirements and accreditation standards (NCQA preferred).
• Excellent presentation and facilitation skills.
• Strong analytical and critical-thinking abilities.
• Ability to interpret clinical documentation and medical policy.
• Excellent written and verbal communication skills.
• Proficiency with UM systems and Microsoft Office applications.
• Strong organizational skills and ability to manage multiple priorities.

Qualifications:

• Bachelor’s or Master’s degree in Nursing, Healthcare Administration, Public Health, or related field required.
• Clinical (active and unrestricted) licensure (e.g., RN) required.
• 5–10+ years of experience in a clinical setting.
• 5+ years of experience in health plan Utilization management.
• 2+ years of experience in training, auditing, quality assurance and/or education role.
• Experience with healthcare technology (e.g., EHR systems like Epic or Cerner, clinical decision support).
• Deep knowledge of healthcare regulations (e.g., CMS, HIPAA, Joint Commission) and clinical quality programs.
• Strong analytical, communication, and stakeholder engagement skills.
• Strong knowledge of NCQA standards, CMS guidelines, and state/federal regulations.
• Experience with medical necessity criteria tools (InterQual, MCG, or similar).

Preferred Qualifications:

• Prior audit experience within a managed care or health plan setting preferred.
• Experience with value-based care models, ACOs, or population health strategies.
• Certification in Lean Six Sigma, PMP, or healthcare quality (e.g., CPHQ).

Pay: $75,962.00 - $100,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance
• Work from home

Experience:

• health plan UM: 5 years (Required)
• training, auditing and quality assurance: 2 years (Required)

License/Certification:

• RN License (Required)

Work Location: Remote