Clinical Medical Review Auditor

Plan, coordinate, deliver, and evaluate clinical training programs, including onboarding, annual training, customer service, quality and performance metrics, professional development, compliance, and regulatory training. Plans, develops, delivers, coordinates, and evaluates clinical education programs for health plan clinical operations staff.

Clinical Trainer and Auditor
Job Summary

Plans, develops, delivers, coordinates, and evaluates clinical education programs for health plan clinical operations staff. Training includes new-hire orientation, annual training, model of care training, accreditation preparation, and regulatory requirements.

Responsibilities

• Consult with clinical operations leaders to identify and address training needs.
• Develop, maintain, and revise training curricula.
• Plan, coordinate, deliver, and evaluate clinical training programs, including onboarding, annual training, customer service, quality and performance metrics, professional development, compliance, and regulatory training.
• Serve as a resource for clinical practice and professional development through coaching, mentoring, feedback, and motivation.
• Serve as a subject matter expert on policies, procedures, and operational requirements related to accreditation and regulatory standards.
• Use varied training methodologies, instructional techniques, learning tools, and practices.
• Provide online and conference-call training for remote employees.
• Develop practical exercises that provide effective hands-on learning for new and existing employees.
• Monitor and report on the effectiveness of education and training programs.
• Create targeted training for employees who do not meet or maintain performance standards.
• Develop audit tools that meet applicable accreditation and regulatory requirements.
• Perform case reviews, audits, and inter-rater reliability analyses according to established standards.
• Audit staff phone calls and written documentation according to policy.
• Conduct periodic audits of health risk assessments, evaluations, care assessments, care plans, and medical necessity documentation to ensure compliance.
• Maintain documentation of staff training according to accreditation and regulatory requirements.
• Collaborate with training and workforce development teams.
• Participate in continuing education and remain current in accreditation, medicine, behavioral health, social determinants of health, and managed care.
• Perform other duties as assigned.
• Maintain thorough knowledge of medical coverage guidelines and organizational policies.
• Assist with policy and practice guideline development and revisions, and provide coaching to support individual and departmental goals.
• Comply with applicable organizational policies, procedures, privacy requirements, accreditation standards, and quality management expectations.

Requirements

• At least three years of clinical care experience.
• At least two years of experience in a managed care setting.
• Experience with accreditation surveys, regulatory program audits, operational reviews, and clinical audits.
• Bachelor s degree in nursing.
• Active, current, unrestricted licensure as a registered nurse or qualified behavioral health professional.
• Ability to obtain or maintain any required professional credentials.

Summary Qualification

• Clinical training and education experience.
• Knowledge of accreditation, regulatory, and certification requirements.
• Experience developing curricula, training programs, and audit tools.
• Strong clinical knowledge and understanding of medical and behavioral health operations.
• Ability to interpret policies, procedures, programs, guidelines, and data.
• Strong communication, collaboration, presentation, coaching, and mentoring skills.
• Ability to manage multiple priorities and meet deadlines.
• Strong analytical, organizational, and problem-solving skills.

Skills

• Intermediate proficiency with word-processing, spreadsheet, database, and presentation software.
• Ability to learn and use new applications and technology.
• Ability to collaborate with information technology teams to support compliance and system utilization.
• Ability to communicate outcomes and recommendations to leadership.
• Preferred advanced computer proficiency.
• Preferred experience with formal instructional design methodologies and competency-based training.
• Preferred experience developing complex or enterprise-wide training programs.
• Detail-oriented, results-driven, and highly organized.
• Effective presentation and instructional skills.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.