Clinical Trainer, Auditor – Utilization Management Experience

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

📋 Description

• Design, implement, and assess clinical training programs and auditing activities for Utilization Management and Care Management.

• Create training modules on clinical philosophy, evidence-based practices, documentation standards, regulatory requirements, and operational workflows.

• Identify training needs and measure effectiveness through feedback, knowledge assessments, audit trends, and performance metrics.

• Oversee onboarding and training preparedness, which includes system access, resource allocation, checklists, and resolution of technical issues.

• Conduct quality audits of Utilization Management activities, medical director decisions, Care Management, and Health Management documentation.

• Perform inter-rater reliability assessments and assist with remediation and performance enhancement initiatives.

• Lead the calibration and standardization of clinical criteria, policies, workflows, and documentation standards.

• Present case updates and findings to managers, supervisors, and medical directors.

• Review and update policies, procedures, training materials, job aids, facilitator guides, and workflow resources.

• Facilitate practical technical training, guided practice sessions, mock scenarios, competency evaluations, and follow-up coaching.

• Coordinate cross-departmental support among IT, new employees, and operational teams.

• Ensure compliance with state, federal, AZ Blue, URAC, CMS, and other regulatory and accreditation standards.

⛳️ Requirements

• Minimum of 5 years of direct clinical care experience in a healthcare environment.

• At least 2 years of experience in Utilization Management, Care Management, Health Management, Disease Management, or comparable managed care operations.

• A minimum of 4 years of experience in clinical training, education, auditing, or quality improvement, ideally within managed care.

• Associate degree in a general field of study or a Post High School Nursing Diploma.

• An active, current, and unrestricted Arizona license or endorsement as a behavioral health professional, RDN, or CDCES; OR an active, current, and unrestricted RN license in Arizona or another NLC state; OR an active, current, and unrestricted Arizona LPN license.

• Preferred: 5 years of experience in clinical education, training, auditing, quality improvement, and instructional design within Utilization Management or Case Management.

• Preferred: 1 year of experience with Milliman Care Guidelines (MCG) or similar clinical criteria/guidelines.

• Preferred: experience in conducting clinical audits, quality reviews, or inter-rater reliability assessments.

• Preferred: experience in supporting onboarding, staff development, remediation, or performance enhancement for clinical personnel.

• Preferred: master's degree in nursing, social work, behavioral health, psychology, or a related clinical field.

• Preferred certifications such as CCM, CPHQ, BCBA, or Utilization Management certification.

• Strong skills in written and verbal communication, organization, analysis, reporting, computer use, and technology.

• Proficiency in Word, Excel, PowerPoint, SharePoint, Microsoft Teams/Webinar, and Internet use.

• Ability to comprehend workflows and develop and implement integrated policies, procedures, work plans, and solutions.

• Capacity to collaborate with stakeholders across various business sectors and work independently.

• Knowledge of healthcare costs and quality challenges, patient education, behavior change strategies, Adult Learning Theory, managed care, utilization management, quality management, and CPT/HCPCS and ICD-10 coding.

• Ability to maintain confidentiality and privacy, prioritize multiple tasks, exercise sound judgment, and resolve problems effectively.

• Ability to represent AZ Blue professionally within the community.

🏝️ Benefits

• Remote work option with no regular onsite obligations.

• Full-time commitment of at least 40 hours per week.

• Opportunities for continuing education participation.

• Training and professional development opportunities available.

• Work that supports over one million Arizonans.

• Health insurance products and services provided by the employer.