Clinical Group Health Trainer

This is a fully remote position, open to applicants in United States.

📋 Description

• **JOB SUMMARY**

• The Group Health Training and Auditing Specialist (GH Trainer) is tasked with providing structured training and continuous education to both new hires and existing staff, while pinpointing areas for development, growth, and remediation. This position is pivotal in enhancing employee performance, job satisfaction, and client outcomes by tracking trends such as clarifications, turnaround times (TAT), and overturn rates.

• The success of Dane Street is dependent on the contributions of individuals and teams every day. We prioritize the well-being of our customers, one another, and Dane Street itself. It is our collective responsibility to foster a positive work environment that encourages client satisfaction and favorable results.

• **MAJOR DUTIES & RESPONSIBILITIES**

• - Onboard and train all new QA hires.

• - New QAs will be deemed ready for integration into the operations team once the following criteria are satisfied:

• - Proficiency on one core client (≤ 2% clarification rate)

• - Division 1: HCSC

• - Division 2: BCBS MN

• - Division 3: Optum

• - Daily output of ≥ 5 cases

• - Collaborate in reviewing daily operational reports (e.g., outcome reports, TAT, operational synopsis, employee goals).

• - Act as a resource for team members regarding operational inquiries, concerns, and problem-solving.

• - Provide backup support to QA Supervisors as necessary (e.g., invoicing, board balance).

• - Maintain a weekly clarification tracker; identify QAs who require further training or feedback.

• - Participate in client calls.

• - Lead bi-weekly Clarification/TAT review meetings: gather data, facilitate discussions, and develop remediation plans.

• - Conduct regular MFR (member-friendly rationale) Workshop training sessions.

• - Develop onboarding agendas in collaboration with Ops Leadership.

• - Identify and organize training opportunities/meetings.

• - Coordinate and monitor annual client regulatory training requirements.

• - Assist with regulatory accreditation audits (e.g., NCQA, URAC).

• - Provide backup support to the GH Auditor during client collaboration audits (e.g., BCBSMN monthly, HCSC quarterly and annually).

• - Update and maintain severity and client-change trackers.

• - Create and manage training documentation.

• - Collaborate on remediation plans for employees.

• - Provide reviewer training when a Medical Director is unavailable; escalate issues to Medical Directors as necessary.

• - Partner with managers and supervisors to facilitate 90-day reviews, annual evaluations, and PIPs.

• Performance Metrics:

• - Audit Success: Assessed by clarification rates, audit outcomes, and daily/monthly TAT.

• - Remediation Effectiveness: Performance improvement measured within established timelines.

• - Training Success: Evaluated through 90-day and annual employee reviews, along with regular check-ins with new hires (daily, weekly, monthly).

• Other duties & special projects as assigned, based on business needs.

⛳️ Requirements

• **Qualifications:**

• - RN or LPN license is mandatory.

• - Strong experience in clinical operations, training, or quality assurance.

• - Extensive knowledge in utilization review, with a solid foundation in health plan practices.

• - Familiarity with navigating CMS requirements, health plan criteria, and nationally recognized guidelines such as MCG and InterQual.

• - Proficient in rationale writing and converting it into patient-friendly language.

• - Exceptional communication, coaching, and mentoring abilities.

• - Capability to analyze data and identify trends to enhance performance.

• - Skilled in client collaboration and escalation management.

• - Proficient in Google Suite, communication platforms, and related applications.

• Preferred Experience Includes:

• - Benefit Denials

• - Medical Necessity Reviews

• - EIU Reviews

• - Criteria-Only Reviews

• - Formulary Exception Reviews

• - Quantity Limit Reviews

• - Step Therapy Reviews

• - Inpatient vs Observation Reviews

• - Level of Care Reviews

• - Claims Reviews

• - Payment Integrity Reviews

• - DRG Validation

• - Quality of Care Reviews

• - Fraud, Waste, and Abuse (FWA) Reviews

• **JOB RELATED SKILLS/COMPETENCIES:**

• Comprehensive knowledge of relevant guidelines. Strong understanding of medical terminology, critical thinking abilities, and effective time management to meet specific deadlines. Exceptional communication skills along with a clear understanding of company business lines. Computer literacy and typing skills are essential.

🏝️ Benefits

• Join our team at Dane Street and take advantage of a comprehensive benefits package designed to enhance your well-being and peace of mind. We provide a variety of benefits including medical, dental, and vision coverage for you and your family. Additionally, voluntary life insurance options are available for you, your spouse, and your children. We also offer various voluntary benefits such as hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy allows you to relax and recharge, while our 401k plan with a company match assists you in planning for your future. Apple equipment and a media stipend are provided for your remote workspace.