Clinical Specialist, Quality Management I Job at Personify Health

Job Description

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. 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.

Job Responsibility

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
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
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
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: 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
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
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: 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
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
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
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

Requirements

Active, unrestricted Registered Nurse (RN) license required
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
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
Audit execution skills
Adult learning principles and facilitation skills
Training record management and performance trending
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
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
Physical and Mental Requirements: Ability to perform the essential job functions safely and successfully with or without reasonable accommodation
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

Nice to have

Bachelor's degree preferred
2–4 years of UM, CM, and/or DM/CDM experience required
managed care experience preferred
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

What we offer

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

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Clinical Specialist, Quality Management I

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