Position Purpose: Develop, conduct, administer and analyze clinical training programs, conduct audits of clinical systems entry and/or processes, and assist in development of audit tools for Utilization Management team.
Develop and conduct clinical education courses, including case management education and training for new employees
Develop and maintain complex audit processes and audit tools related to authorizations, appeals, quality, case management, inter-rater reliability and data entry
Audit established guidelines (e.g. Interqual) for medical necessity
Analyze training needs and identify, select or develop appropriate training programs including training aids and materials
Audit staff in accordance with established auditing processes, work with staff to identify and resolve errors in data and reporting, and present findings and recommendations for improvement to management
Train audit staff in the use of audit tools and identification of patterns or trends that require additional training or corrective action
Evaluate effectiveness of training programs including cost/benefit analyses
Research, analyze, and recommend internal/external training programs
Maintain records of training activities and employee progress
Assist with revisions to Policy and Procedure and/or work process development
Participate in Quality and Advisory committees) or provider education meetings
Travel may be required
Education/Experience: Bachelor’s degree in Nursing, related clinical field or equivalent experience. 4+ years of experience in nursing, training, or auditing in a managed care healthcare setting. Experience in a lead or supervisory role preferred.
License/Certification: Current state nursing license, RN or LPN. Driver’s license may be required for certain positions.
Must have experience in Utilization Management including concurrent review and prior authorizations.
Experience with Interqual highly preferred.
What are the 3-4 non-negotiable requirements on this position?
- Experience training and/or curriculum design - UM experience- concurrent review, prior auth - Managed care experience with provider or MCO - Proficient with Microsoft Office - Must have RN or LPN (RN highly preferred)
What are the nice-to-have skills?
- Experience with Interqual - Strong organization skills - Strong verbal and written communication