Clinical Group Health Trainer

Major Duties & Responsibilities

• Onboard and train all new QA hires
• New QAs will be ready for integration into the ops team when the following criteria are met:
• Proficiency on one core client (≤ 2% clarification rate)
• Division 1: HCSC
• Division 2: BCBS MNDivision 3: Optum
• Daily output of ≥ 5 cases
• Collaborate on the review of daily operational reports (e.g., outcome reports, TAT, operational synopsis, employee goals)
• Serve as a resource for team members regarding operational questions, concerns, and problem-solving
• Provide backup support to QA Supervisors as needed (e.g., invoicing, board balance)
• Maintain weekly clarification tracker; identify QAs with opportunities for additional training or feedback
• Participate in client calls
• Lead bi-weekly Clarification/TAT review meetings: pull data, facilitate discussions, and issue remediation plans
• Conduct regular MFR (member-friendly rationale) Workshop training sessions
• Develop onboarding agendas in consultation with Ops Leadership
• Identify and schedule training opportunities/meetings
• Coordinate and track annual client regulatory training requirements. Support regulatory accreditation audits (e.g., NCQA, URAC)
• Provide backup support to GH Auditor in performing client collaboration audits (e.g., BCBSMN monthly, HCSC quarterly and annual)
• Update and maintain severity and client-change trackers
• Create and maintain training documentation
• Collaborate on remediation plans for employees
• Provide reviewer training when a Medical Director is unavailable; escalate issues to Medical Directors when appropriate
• Partner with managers and supervisors to support 90-day reviews, annual evaluations, and PIPs

Performance Metrics

• Audit Success: Measured by clarification rates, audit results, and daily/monthly TAT
• Remediation Effectiveness: Measurable performance improvement within defined timelines
• Training Success: Evaluated through 90-day and annual employee reviews, and check-ins with new hires (daily, weekly, monthly)

Requirements

• RN or LPN license required
• Strong background in clinical operations, training, or quality assurance
• Extensive experience in utilization review, with a strong background in health plan practices
• Experienced in navigating CMS requirements, health plan criteria, and nationally recognized guidelines such as MCG and InterQual.
• Proficient in rationale writing and translation to patient-friendly language
• Excellent communication, coaching, and mentoring skills
• Ability to analyze data and identify trends to drive performance improvements
• Skilled in client collaboration and escalation management
• Proficiency with Google Suite, communication platforms, and related applications

Preferred Experience

• Benefit Denials
• Medical Necessity Reviews
• EIU Reviews
• Criteria-Only Reviews
• Formulary Exception Reviews
• Quantity Limit Reviews
• Step Therapy Reviews
• Inpatient vs Observation Reviews
• Level of Care Reviews
• Claims Reviews
• Payment Integrity Reviews
• DRG Validation
• Quality of Care Reviews
• Fraud, Waste, and Abuse (FWA) Reviews

Skills

• Extensive working knowledge of relevant guidelines
• Excellent understanding of medical terminology, critical thinking, ability to manage time efficiently and to meet specific deadlines
• Present exceptional communication skills with a clear understanding of company business lines
• Computer literacy and typing skills are essential

Working Conditions/Physical Demands

• Any lifting, bending, traveling, etc. required to do the job duties listed above
• Long periods of sitting and computer work

Work From Home Technical Requirements

• Supply and support their own internet services
• Maintaining an uninterrupted internet connection is a requirement of all work from home position

Benefits

• Medical, dental, and vision coverage for you and your family
• Voluntary life insurance options for you, your spouse, and your children
• Other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans
• Basic life insurance, short-term disability, and long-term disability coverage at no cost
• Grossly generous paid time off policy
• Apple equipment and a media stipend are provided for remote workspace

About Dane Street

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers' Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.