Associate Manager Clinical Training (Utlization Management)

JOB DESCRIPTION

This role is part of the training function and will lead and drive clinical knowledge, documentation standards, and proficiency, ensuring consistent application of clinical judgment and audit-ready, defensible documentation across clinical teams.

The role is responsible for strengthening clinical decision-making, improving documentation quality, and advancing proficiency through structured training, clinical review simulations, and calibration across all levels of care, including outpatient, observation, inpatient, LTAC, and post-acute settings (e.g., Home Health, SNF).

Must-Have Criteria (Non-Negotiable)

Must-Have Criteria (Non-Negotiable)

Candidates must demonstrate:

• 5+ years Utilization Management experience across the continuum of care, including:
• Outpatient / procedural review
• Inpatient and observation
• Post-acute (LTAC, SNF, Home Health)
• Hands-on application of MCG Health criteria for:
• Admission
• Continued stay
• Discharge / transition planning
• Experience with Interqual criteria is an advantage
• Proven experience independently making and defending medical necessity decisions
• Experience in calibration, QA, or Inter-Rater Reliability (IRR) activities
• Exposure to training, coaching, or Train-the-Trainer (TTT)
• Familiarity with URAC and National Committee for Quality Assurance Standards

KEY RESPONSIBILITIES

• Provide expert-level guidance across all levels of care, including:
• Outpatient and procedural utilization review
• Inpatient admission vs observation determinations
• Concurrent/continued stay reviews
• LTAC admission, continued stay, and discharge appropriateness
• Home Health authorization and recertification review
• Support complex and escalated cases involving:
• High-acuity conditions and multiple comorbidities
• Prolonged stays and discharge barriers
• Post-acute care transitions across the continuum
• Ensure defensible clinical decisions aligned with MCG criteria (primary) and InterQual (as applicable) and documentation standards

• Work closely with Operations and clinical teams to ensure Clinical Rounds sessions are conducted effectively and consistently, focusing on:
• Reinforcement of advanced clinical reasoning and criteria application
• Standardized interpretation across all levels of care
• Review of high-risk and frequently misclassified cases
• Drive Inter-Rater Reliability (IRR) through:
• Calibration sessions with QA, Operations, and client reviewers
• Alignment on level-of-care and continued stay determinations
• Identify variability in:
• Inpatient vs observation decisions
• Continued stay justification
• Post-acute utilization (LTAC, SNF, Home Health)
• Translate insights from Clinical Rounds and IRR into:
• Case libraries and clinical review simulation scenarios
• Decision frameworks and job aids
• FAQs targeting recurring clinical judgment gaps
• Implement targeted interventions to improve:
• Decision consistency
• Documentation quality and defensibility
• Audit readiness and regulatory compliance

• Train and mentor trainers and clinical teams on:
• Clinical content accuracy
• Criteria application (MCG primary, InterQual as applicable)
• Case facilitation and coaching effectiveness

• Lead the development and continuous improvement of clinical content for Foundation Training and supplemental clinical training programs, including:
• Core clinical knowledge and concepts
• Medical necessity and criteria application
• Documentation standards and decision rationale
• Case-based learning and clinical review simulation activities
• Ensure content reflects:
• Current clinical guidelines and regulatory requirements
• Real-world case complexity across all levels of care
• Expected clinical judgment and documentation standards
• Drive the design and use of simulation-based learning to:
• Strengthen clinical judgment and decision-making
• Improve consistency in case evaluation
• Reinforce documentation accuracy and completeness

• Establish and enforce documentation standards to ensure:
• Clear, complete, and clinically sound case documentation
• Alignment with medical necessity criteria and decision rationale
• Readiness for audits, appeals, and regulatory review
• Ensure documentation supports:
• Defensible medical necessity decisions
• Consistent clinical reasoning and criteria application
• Compliance with URAC, NCQA, and CMS requirements
• Identify documentation gaps and trends and:
• Integrate improvements into training and simulations
• Deliver targeted coaching and refresher sessions

• Drive continuous training improvement in:
• Clinical judgment
• Documentation quality
• Criteria application consistency

Minimum Qualifications

• Registered Nurse (RN) – Required
• USRN – Strongly Preferred