Part-Time Clinical Quality Specialist

About the role

The Part-Time Clinical Quality Specialist role exists to safeguard and strengthen the clinical integrity of care delivered across the organization, with a focused lens on utilization management, payor-facing clinical audits, and clinical quality assurance.

This position ensures that care is medically necessary, appropriately documented, and aligned with evidence-based standards and payor requirements supporting both provider success and defensible, compliant clinical operations.

This is a collaborative, provider-supportive role that combines sound clinical judgment with the rigor of utilization review and audit-readiness. The Specialist serves as a key bridge between clinical care, payor expectations, and internal quality standards.

Responsibilities

• Utilization Management & Review:
  • Conduct prospective, concurrent, and retrospective utilization reviews to assess medical necessity, treatment appropriateness, and level of care.
  • Apply evidence-based UM criteria to evaluate clinical documentation and support authorization and appeal processes.
  • Monitor care intensity and utilization trends to identify outliers and inform targeted provider interventions.
  • Partner with health plans on external UR requests and peer-to-peer review coordination.
• Clinical Quality & Provider Support:
  • Investigate and remediate provider concerns stemming from UM findings, client complaints, or external reports.
  • Monitor clinical adverse events and apply early-stage risk mitigation in partnership with cross-functional teams.
  • Support measurement-based care initiatives and identify opportunities to strengthen clinical outcomes across the provider network.
• Reporting & Continuous Improvement:
  • Track utilization metrics, review volumes, and case outcomes to inform quality improvement efforts.
  • Surface trends and process gaps to leadership and contribute to the ongoing refinement of UM policies and workflows.

Requirements

• Master’s degree in a mental health discipline.
• Active, cleared clinical license (e.g., LMFT, LPC, LCSW, LMHC, or equivalent) in good standing.
• Experience in utilization management, utilization review, medical necessity review, or clinical auditing — ideally in a behavioral health or payor/health plan context.
• Familiarity with payor requirements, medical necessity criteria, and level-of-care guidelines.
• Strong clinical judgment and experience handling escalations, adverse events, or quality-related investigations.
• Demonstrated ability to produce clear, accurate, and defensible clinical documentation.
• Demonstrated ability to collaborate effectively across multiple teams.
• Commitment to provider support and quality management.
• Familiarity with clinical technology platforms for documentation, case tracking, and data analysis to support provider quality and compliance.

Qualifications

• Familiarity with job-relevant AI platforms such as Gemini, ChatGPT, Claude, GitHub Copilot or other industry-standard AI productivity tools is expected and considered essential for success at this company.

Benefits

Compensation Range: The hourly rate offered for this role is between $40.00-$42.00/hour, up to 30 hours per week.

Schedule

This is a part-time position, up to 30 hours per week.