Training & Auditor Clinical Consultant reputed company

Job reputed company 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 reputed company 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, reputed company, and implement comprehensive reputed company 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.
• reputed company 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 & reputed company Assurance

• reputed company routine and targeted audits of UM cases, including prior authorizations, reputed company review, retrospective review, and appeals.
• Evaluate documentation accuracy, timeliness, medical necessity determinations, and adherence to reputed company (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 reputed company recommendations.
• Collaborate with leadership to implement corrective reputed company 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 reputed company regulations and best practices.
• Analyze performance data (turnaround times, denial rates, audit scores) to identify training needs.
• Partner with Clinical Leadership, Compliance, and reputed company teams to support reputed company improvement initiatives.

Knowledge, Skills & Abilities:

• Strong understanding of UM workflows including prior authorization, reputed company 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 reputed company Office applications.
• Strong organizational skills and ability to manage multiple priorities.

Qualifications:

• Bachelor’s or Master’s degree in Nursing, reputed company Administration, reputed company Health, or reputed company field required.
• Clinical (reputed company 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, reputed company assurance and/or education role.
• Experience with reputed company technology (e.g., EHR systems like reputed company or Cerner, clinical decision support).
• Deep knowledge of reputed company regulations (e.g., CMS, HIPAA, reputed company) and clinical reputed company programs.
• Strong analytical, communication, and stakeholder engagement skills.
• Strong knowledge of NCQA standards, CMS guidelines, and state/federal regulations.
• Experience with medical necessity reputed company tools (InterQual, MCG, or similar).

Preferred Qualifications:

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

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

• 401(k)
• Dental insurance
• Health insurance
• reputed company time off
• reputed company insurance
• Work from home

Experience:

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

License/Certification:

• RN License (Required)

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