Utilization Management Clinical Trainer

Job Summary

The Utilization Management (UM) Clinical Trainer is responsible for designing, delivering, and maintaining comprehensive training programs that prepare nurses, physicians, and other clinical staff to perform high quality, compliant utilization review within a payer environment. This role ensures clinicians understand UM workflows, medical necessity criteria, regulatory requirements, documentation standards, and payer-specific policies. The trainer supports onboarding, ongoing education, performance improvement, and interrater reliability across all UM functions.

Essential functions:

• Training Program Development & Delivery
• Design and deliver onboarding training for nurses, physicians, and UM reviewers, covering:
• Prior authorization workflows
• Concurrent review processes
• Inpatient/observation review
• SNF and post-acute review
• Medical necessity criteria (e.g., MCG, InterQual)
• Payer policies and benefit structures
• Create standardized training materials, curricula, job aids, and competency assessments.
• Customize training for role type (RN reviewer, physician reviewer, coordinator) and system differences (applications, documentation platforms, phone vs. non phone roles). [
• Deliver training via virtual, in person, and hybrid formats.
• Quality, Compliance & Regulatory Alignment
• Ensure training content aligns with NCQA, URAC, CMS, HIPAA, state regulations, and payer-specific requirements.
• Reinforce documentation standards, audit expectations, and compliance protocols.
• Provide remediation training based on audit findings, quality trends, or performance gaps.
• Collaboration & Stakeholder Engagement
• Partner with Medical Directors, Clinical Leadership, and Executive Leadership Teams to ensure training aligns with operational goals.
• Participate in quality improvement initiatives and contribute to UM operational performance metrics.
• Maintain a centralized repository of training materials, schedules, and documentation.

Competencies:

• Clinical judgment and UM expertise
• Instructional design and adult learning principles
• Regulatory and compliance literacy
• Data-driven performance analysis
• Stakeholder collaboration
• Change management and communication
• High attention to detail and documentation accuracy

Required education and experience:

• Active RN license or equivalent clinical credential; physician training experience preferred.
• 3 - 5+ years of Utilization Management experience within a payer or managed care environment.
• Strong knowledge of medical necessity criteria (MCG, InterQual), CMS guidelines, and payer authorization processes.
• 2+ years experience training clinicians or leading clinical education programs.
• Excellent communication, facilitation, and curriculum development skills.

Preferred education, certifications and/or experience:

• Bachelor’s degree in Nursing, Social Work, Healthcare Administration, or related field.
• Experience with UM systems (e.g., GuidingCare, TruCare, Jiva, Epic UM modules).
• Prior experience with NCQA/URAC accreditation standards.
• Background in quality improvement, audits, or interrater reliability programs.

Physical Requirements/Work environment:

• Remote role with occasional travel (Less than 5%)
• Prolonged periods of sitting at a desk and working on a computer.
• Ability to speak, hear, and comprehend both written and verbal communications.
• Must have a home office, mobile phone, computer with security requirements met.
• Internet Speed Minimum of 100 Mbps download and 10–20 Mbps upload
• Typing/data entry of 30 WPM

Other duties:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without advanced notice.

Pay: From $48.00 per hour

Experience:

• training clinicians: 2 years (Required)
• Utilization Management experience within a payer : 3 years (Required)

License/Certification:

• RN license or equivalent clinical credential (Required)

Work Location: Remote