Clinical Trainer and Auditor - Case Management Experience - Remote-AZ

Blue Cross Blue Shield of Arizona•Phoenix, AZ

20h•Remote

About The Position

Responsible for designing, delivering, and evaluating clinical training programs and audit activities that promote standardized clinical decision-making, regulatory compliance and quality improvement across Utilization Management and Care Management initiatives. This role supports staff development, onboarding, inter-rater reliability, and ongoing education for clinical teams to enhance performance, operational consistency, and achievement of organizational goals and initiatives.

Requirements

5 years of direct clinical care experience in a healthcare setting
2 years of experience in Utilization Management, Care Management, Health Management, Disease Management, or other managed care operations.
4 years of experience in clinical training, education, auditing, or quality improvement, preferably in managed care.
Associate degree in general field of study or Post High School Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC, LMFT, or licensed psychologist (Psy.D. or Ph.D.),or RDN (Registered Dietitian Nutritionist), CDCES (Certified Diabetes Care and Education Specialist), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN.
Strong written and verbal communication skills.
Excellent organizational skills and strong attention to detail
Possess proficient computer and technological skills especially Word, Excel, PowerPoint, SharePoint, Microsoft Teams/Webinar, and Internet
Ability to gather, analyze data and prepare informative and accurate reports.
Ability to understand the workflow of multiple components of the company and to assist in the creation and implementation of integrated policies, procedures, workplans and creative solutions.
Ability to develop, organize, motivate, coordinate, and collaborate effectively with stakeholders from multiple business areas across the organization.
Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions, strong competition and restructuring.
Strong understanding of the costs/quality challenges of today’s health care environment.
Knowledge of health and/or patient education and behavior change techniques.
Organizational skills to analyze, interpret data, synthesize, evaluate and explain educational concepts, practices and methodologies to staff and transfer data to and from written and verbal medium.
Ability to maintain confidentiality and privacy
Advanced knowledge of Adult Learning Theory principles and demonstrated ability to facilitate training that resonates with all learning styles
Demonstrate strong interpersonal and active listening skills
Demonstrated organizational skills with the ability to priortize tasks and work with multiple priorities
Follow and accept instruction and direction
Establish and maintain working relationships in a collaborative team environment
Apply independent and sound judgment with good problem solving skilll
Desire and capability to drive toward and achieve high standard of quality and results.
Mindset geared toward the creation, execution and continuous improvement of clinical benefit management department and programs.
Intellectual curiosity and ability to view old problems/issues with a fresh perspective.
Ability to perform job duties independently.
Ability to professionally represent AZ Blue in the community.

Nice To Haves

5 years of experience in clinical education, training, auditing, quality improvement, and instructional design in either Utilization Management or Case Management.
1 year of experience working with Milliman Care Guidelines (MCG), and / or other clinical criteria/guidelines.
Experience conducting clinical audits, quality reviews, or inter-rater reliability assessments related to evidence-based clinical decision making, documentation accuracy, and regulatory or accreditation standards.
Experience supporting onboarding, staff development, remediation, or performance improvement initiatives for clinical staff.
Master’s degree in nursing, Master of Science, Social Work, Behavioral Health, Psychology, or another related clinical field.
Active and current certifications such as: Certified Case Manager (CCM), Certified Professional in Healthcare Quality (CPHQ), Board Certified Behavior Analyst (BCBA), or a Utilization Management Certification related to evidence-based clinical criteria such as MCG.
Advanced PC proficiency
Knowledge of CPT/HCPCs and ICD-10 coding
Knowledge of managed care, utilization management, and quality management

Responsibilities

Develop and deliver training and education for clinical staff on clinical philosophy, evidence-based practice, documentation standards, regulatory requirements, and operational workflows related to Utilization Management, Care Management and Health Management.
Assess and prioritize training needs based on workflow changes, audit findings, stakeholder feedback, business priorities, and staff readiness.
Evaluate training effectiveness using feedback, knowledge checks, audit trends, and performance data to identify gaps and recommend improvements.
Assist with the development and evaluation of performance goals, quality management activities, and improvement initiatives that support clinical, operational, and regulatory standards.
Coordinate onboarding and training readiness activities, including system access, required resources, non-clinical checklists, and resolution of technical barriers.
Perform quality audits for Utilization Management activities and medical director determinations to evaluate consistency, accuracy, and compliance in evidence-based clinical decision-making, including inter-rater reliability assessments for Utilization Management as applicable.
Audit activities assess whether medical director’s determinations are clear, concise, and documented to support clinical reviewers’ understanding and next-step action.
Perform quality audits for Care Management and Health Management activities to assess accuracy and completeness of documentation, alignment of interventions with care plans, and progression toward member outcomes and goals.
Support targeted education, remediation, and performance improvement initiatives based on audit findings, operational needs, and quality management priorities.
Support process improvement initiatives by providing education, workflow guidance, and technical application support to clinical staff and stakeholders.
Facilitate calibration and standardization activities to support consistent application of clinical criteria, policies, workflows, and documentation expectations.
Present case status updates and relevant findings to the manager, supervisor, and when indicated, the medical director to support clinical oversight, decision making, and appropriate follow-up.
Assist with the review, revision, and ongoing maintenance of policies and procedures to ensure alignment with regulatory requirements, organizational standards, and evidence-based clinical practice.
Assist with ad hoc training assignments and educational initiatives as needed to support departmental priorities, workflow changes, and staff development.
Maintain compliance with applicable state, federal, AZ Blue, URAC, CMS and other regulatory and accreditation standards.
Maintain complete, accurate, and timely records in accordance with department policies, procedures, and documentation standards.
Participate in continuing education and remain current on developments in clinical practice, medicine, managed care, and applicable regulatory requirements.
Facilitate hands-on technical training for Care Management, Health Management, and Utilization Management workflows, including system navigation, documentation expectations, authorization entry, assessment completion, mock scenarios, and guided practice.
Develop training plans with learning objectives, workflow scenarios, guided practice, competency checks, and follow up coaching to support readiness for independent work.
Develop, maintain, version control for training materials, job aids, facilitator guides, and workflow resources to ensure accuracy, consistency, and alignment with current standards.
Coordinate cross-functional support between IT, new hires, and operational teams to address system access and application issues.
Facilitate structured onboarding using non-clinical checklists to ensure all requirements are completed.
Ensure system access readiness by validating functionality, conducting required testing, and verifying availability of tools and resources.
Utilize training environments to reinforce system proficiency through structured practice, guided navigation exercises, mock scenarios, and hands-on demonstrations of CM, HM, and UM workflows, including assessment completion and authorization entry.
Perform all other duties as assigned.