Clinical Specialist, Quality Management and Training

TL;DR

Clinical Specialist, Quality Management and Training (Healthcare): Ensuring regulatory and quality compliance across clinical operations with an accent on audits, training, and risk management. Focus on conducting internal/external audits, developing evidence-based training materials, and collaborating with teams to uphold standards like HIPAA, NCQA, URAC.

Location: Remote, United States

Salary: $60,600 - $91,000

Company

Personalized health platform bringing together health plan administration, holistic wellbeing solutions, and care navigation to reduce costs and improve health outcomes.

What you will do

• Ensure compliance with state, federal, and accreditation standards including ERISA, NCQA, URAC, HIPAA.
• Conduct internal/external audits of clinical programs, prepare reports, and participate in case file preparation.
• Monitor clinical activities for protocol adherence, identify/manage risks, review/approve SOPs, and implement improvements.
• Train clinical staff on regulations, quality standards, and objectives using various modalities; develop training materials and tools.
• Track training progress, report on staff performance, conduct quality audits, and support corrective action plans.
• Maintain knowledge of regulations and practices; demonstrate proficiency in Microsoft Office and Smartsheet.

Requirements

• Active unrestricted Registered Nursing License required; additional licensure may be needed
• Bachelor’s Degree preferred
• 3-5 years UR, CM, DM experience required; managed care experience preferred
• CPHQ and/or CCM certification preferred
• In-depth knowledge of HIPAA, CMS, NCQA, URAC; audit skills, analytical thinking, communication
• Proficiency in Microsoft Office, Smartsheet, SharePoint, Teams, and other tools after training

Nice to have

• 3 years experience leading, mentoring, training staff
• Advanced coursework in teaching/mentoring
• Familiarity with medical claims, ICD-10, CPT, HCPCS coding

Culture & Benefits

• Competitive base salary and full benefits package starting day one, including medical/dental
• Unlimited PTO
• Mental health support, retirement planning, financial protection
• Professional development with career progression and learning budgets
• Mission-driven culture emphasizing diversity, equity, inclusion