Clinical Specialist, Quality Management I

Personify Health • Remote,

1d • $60,600 - $91,000 • Remote

About The Position

The Clinical Specialist, Quality Management & Training is a licensed clinical professional responsible for regulatory compliance, quality oversight, and workforce education across Utilization Management (UM), Case Management (CM), and Chronic Disease Management (CDM) programs. The role applies independent judgment and discretion to evaluate clinical systems, conduct internal and external audits, support accreditation readiness (e.g., NCQA/URAC), and implement quality and training improvements that strengthen documentation integrity, timeliness, and member protections.

Requirements

• Basic computer literacy
• The ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook
• Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Ability to work independently and utilize written resources to problem solve.
• Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet—there may be additional programs as it relates to particular job duties
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Excellent verbal and written communication skills for upward and downward conversations
• In-depth knowledge of applicable regulations and accreditation standards (HIPAA, CMS requirements as applicable, NCQA, URAC).
• Strong clinical documentation review skills; attention to detail and data integrity mindset.
• Audit execution skills: sampling, evidence validation, audit trail review, and clear report writing.
• Adult learning principles and facilitation skills; ability to explain complex concepts in accessible language.
• Training record management and performance trending; ability to identify learning gaps and target interventions.
• Technology proficiency for remote work and multi-system navigation.
• Active, unrestricted Registered Nurse (RN) license required; additional licensure may be required based on program scope.
• 2–4 years of UM, CM, and/or DM/CDM experience required; managed care experience preferred.
• Demonstrated ability to apply adult learning principles and deliver effective training.

Nice To Haves

• Bachelor’s degree preferred.
• CPHQ and/or CCM certification preferred.
• 2–4 years leading, mentoring, and/or training staff preferred; advanced teaching/mentoring coursework preferred.
• Bachelor’s or Master’s degree preferred.
• 4–6 years of managed care experience in UM, CM, and/or CDM.
• Demonstrated experience in clinical quality, training, or accreditation readiness roles.
• CPHQ, CCM, or other job-relevant certification required.

Responsibilities

• Ensure compliance with state, federal, and accreditation requirements (e.g., HIPAA, CMS, NCQA, URAC, ERISA, as applicable).
• Conduct internal and external audits of UM/CM/CDM processes and documentation; prepare audit files, findings, and corrective action recommendations.
• Identify quality and compliance risks and collaborate with cross-functional partners on mitigation and resolution.
• Review and support SOPs and workflows to ensure regulatory alignment and operational clarity.
• Support external audit readiness activities, including NCQA and URAC evidence preparation and maintenance.
• Develop, maintain, and deliver role-based training curriculum aligned to compliance standards, quality goals, and operational workflows.
• Conduct onboarding and orientation to prepare staff for assigned UM/CM/CDM functions.
• Deliver training using multiple modalities (virtual, self-paced, and one-on-one coaching) tailored to adult learners.
• Ensure training covers applicable processes such as case initiation and closure, documentation standards, high-dollar case monitoring, stop-loss notification, administrative support, customer service, and productivity expectations.
• Evaluate training effectiveness through feedback, observation, and performance data; identify improvement opportunities.
• Maintain training records and competency documentation; track trends and escalate performance concerns as needed.
• Conduct assigned quality audits to identify adherence gaps, documentation issues, and training needs.
• Provide coaching and training support aligned to corrective action plans (CAPs); document outcomes and communicate status to leadership.
• Maintain current knowledge of regulatory, accreditation, and evidence-based practice standards.
• Maintain HIPAA compliance and complete all required training within established timeframes.
• Demonstrate proficiency in Microsoft Office and Smartsheet; meet productivity, quality, and turnaround time expectations.
• Participate in required meetings and maintain professional, collaborative working relationships.

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions
• Unlimited PTO—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level