Clinical Specialist, Quality Management I

Overview Who We Are Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com. Responsibilities Ready To ESSENTIAL DUTIES AND RESPONSIBILITIES: 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. What You'll Actually Do Level I – Clinical Specialist I (Foundational) Regulatory Compliance & Quality Oversight 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. Training & Curriculum Delivery 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. Training Effectiveness & Corrective Action Support 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. Professional Standards & Productivity 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. Level II – Clinical Specialist II (Experienced / Advanced Individual Contributor) Advanced Audit Leadership & Program Ownership Serve as coordinator for at least one audit engagement; lead readiness activities and respond to auditor requests in collaboration with leadership. Conduct higher-complexity audits requiring advanced interpretation of regulations, accreditation standards, and clinical documentation requirements. Translate complex regulatory and accreditation requirements into actionable SOP updates, workflow clarifications, and training enhancements. Training Leadership & Innovation Leverage 3–5 years of experience leading, mentoring, and/or training staff; adapt teaching methods to varied learning styles and staff experience levels. Complete advanced teaching and/or mentoring coursework (or equivalent) and apply innovative approaches to deliver best-in-class managed care education. Lead innovation efforts and promote continuous learning initiatives that improve UM/CM/CDM performance and documentation quality. Data Analysis, Reporting & Cross-Functional Collaboration Analyze audit results and training metrics to identify trends; recommend system-level improvements and targeted retraining plans. Demonstrate expert-level proficiency in Microsoft Office Suite and Smartsheet; use data tools (e.g., Excel and/or Power BI where available) to support reporting and visualization. Represent the department in cross-functional compliance initiatives and process improvement work, ensuring alignment with organizational goals. Senior – Senior Clinical Specialist (Lead Individual Contributor; No Direct Reports) Enterprise Training & Quality Leadership (Lead Individual Contributor) Partner with management to develop, refine, and standardize training documents that support departmental standards, regulatory requirements, and strategic goals. Design, maintain, and continuously enhance formal training curricula that promote best practices, compliance adherence, and quality objectives across UM, CM, and CDM programs. Lead new hire onboarding by coordinating training schedules, preparing materials, and ensuring a smooth transition into operational workflows. Deliver and oversee training across multiple modalities (virtual, self-paced, and one-on-one) for adult learners with varied clinical experience levels. Provide training on key functional areas including case creation, stop loss notification, high-dollar case monitoring, documentation standards, customer service expectations, and productivity requirements. Training Effectiveness & Performance Monitoring Gather and analyze training feedback, surveys, and performance data to evaluate effectiveness and identify opportunities for improvement. Maintain accurate training records, staff competency documentation, and performance trend reports. Notify leadership of staff who are not meeting expectations and support corrective action training efforts as directed. Quality Program Governance & Accreditation Readiness Prepare and present components of the Annual Quality Management Program Review to the Quality Improvement Committee (QIC), including metrics, trend analysis, barrier identification, and improvement planning. Lead sustained accreditation readiness activities, including NCQA and URAC preparation, evidence validation, and training documentation integrity. Maintain expert-level understanding of regulatory requirements to ensure ongoing compliance of training content and quality processes. Influence, Communication & Professional Standards Exercise sound judgment in escalating departmental or staff concerns through appropriate channels. Guide staff on procedures, resolve complex or non-routine training and compliance issues, and support operational consistency without direct supervisory authority. Represent Clinical Education & Quality in cross-functional initiatives and enterprise projects. Promote team cohesion, professionalism, and a culture of continuous learning. KEY COMPETENCIES: To work in the health industries and to work remotely, it has been demonstrated that those with computer skills work better in these remote job descriptions. Qualifications What You Bring to Our Team UPON HIRE, must have: 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. After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in: 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 Level I 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. Level II Advanced regulatory interpretation and translation into policies, procedures, and training. · Audit ownership for external engagements and coordination of evidence response. · Trend analysis and data storytelling to drive sustainable process improvement. · Instructional adaptability across varied learner needs; mentoring/coaching (non-supervisory). · Strong collaboration skills across departments and stakeholders. Senior · Advanced clinical regulatory and accreditation knowledge (HIPAA, NCQA, URAC, CMS as applicable). · Enterprise training design, facilitation, and governance. · Audit leadership, quality analysis, and corrective action implementation. · Ability to influence outcomes without direct authority. · Clear executive-level written and verbal communication. QUALIFICATIONS: Level I Active, unrestricted Registered Nurse (RN) license required; additional licensure may be required based on program scope. Bachelor’s degree preferred. 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. Level II Bachelor’s or Master’s degree preferred. 4–6 years of clinical quality assurance, compliance, or equivalent managed care experience. CPHQ and/or CCM certification preferred. 2–4 years leading, mentoring, and/or training staff preferred; advanced teaching/mentoring coursework preferred. Senior 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. Physical and Mental Requirements: Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards. Ability to maintain regular, punctual attendance. Ability to sit for 6-8 hours. Constant use of computer keyboard and mouse; repetitive use of both hands. Occasional to frequent twisting of neck; occasional bending of neck and at waist. This job description is not an exclusive or exhaustive list of all job functions that an employee in this position may be asked to perform. Duties and responsibilities can be changed, expanded, reduced, or delegated by management to meet the business needs of MedCom a Personify Health Company Benefits The Highlights: Competitive base salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use what we build) 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 Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks. Compensation: This position offers a base salary range of $60,600 - $91,000 depending on location, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected]. View all legitimate openings at personifyhealth.com/careers.