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Clinical Trainer (Utilization Management)

Clinical Trainer (Utilization Management)


Job Description


Why CalOptima?

CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. If you're looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.


Job Summary


The Clinical Trainer Registered Nurse (RN), Utilization Management (UM) identifies, monitors and oversees training activities within the Utilization Management department and any targeted UM trainings for other CalOptima departments. The incumbent provides training needs of the department, as well as identification of robust tools to address unique adult learning style and measurement of success. The incumbent captures individual and programmatic trends to make recommendations for additional training based on audit outcomes. Specific areas of focus include but are not limited to: compliance with regulatory requirements, departmental processes, inputs from other customers, such as providers, as well as consistent application of clinical criteria across the department. The incumbent ensures that all CalOptima policies and procedures as well as regulatory requirement changes are communicated to the team. The incumbent works collaboratively with UM management and works across all areas of the department.


Position Responsibilities:


• Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.

• Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.

• Trains, audits, supervises, and coaches UM staff. Informs supervisors of trends to address performance opportunities and/or counseling/corrective action to ensure the team's training needs are met and there is a thorough understanding and application of regulatory requirements and CalOptima policies.

• Identifies new learning opportunities for staff such as developing training materials (e.g. workflows, desktop procedures, PowerPoint presentations, training plans and calendar activities) to provide education.

• Identifies training needs within UM and creates presentations that convey the concepts, as well as provide examples to demonstrate the topic of discussion and validate knowledge of the trainees. Trainings will be a combination of in-person, self-paced and virtual modalities depending on the curriculum and the needs of the trainee.

• Uses systems demos, screen prints and desktop tools to help team members with consistent adoption of workflows and branching sequences of UM activities in the clinical system.

• Ensures understanding of application of medical necessity criteria through multidisciplinary forums whereby case discussion and application of criteria occur including cross functional inter-rater reliability sessions with Medical Directors.

• Assists with the collection, monitoring and analysis of UM indicators and activities to develop training curriculum that addresses the needs of the department.

• Works collaboratively with the UM management for prior authorization, concurrent review, and UM monitoring to ensure appropriate trainings are developed and delivered to staff.

• Spearheads the onboarding process for all UM staff to ensure effective training techniques to ensure understanding and concepts.

• Provides just in time training for those concepts that teammates have a difficult time grasping.

• Provides training and guidance for all CalOptima policy changes as well as regulatory communications, such as All Plan Letters (APLs), WCM Numbered letters and CMS program communications.

• Serves as a resource to departmental staff, internal departments, and affiliated health networks regarding authorization rules, processes and CalOptima policy.

• Reviews workflows, procedures, and/or policies to ensure alignment and recommend or change as appropriate.

• Conducts UM presentations to either internal or external customers.

• Other projects and duties as assigned.


Possesses the Ability to:


• Maintain and ensure confidentiality of patient information.

• Communicate clearly and concisely, both verbally and in writing.

• Provide clear and concise instructions to individuals with varying skill levels.

• Develop training plans and curriculums.

• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

• Access and interpret reports and data.

• Utilize clinical judgment, independent analysis, and evidenced based clinical guidelines in preparation of training materials.

• Grasp UM concepts with accuracy in a timely manner to ensure successful training.

• Handle complex situations with staff.

• Clearly articulate training needs to other departments and assist with curriculum for such training. This would include provider training needs identified related to UM, as well as other departments such as Case Management, Grievance and Appeal Resolution Services, and other departments as appropriate.

• Multitask a variety of projects and responsibilities with varying levels of priority.

• Establish and maintain effective working relationships with CalOptima leadership and staff.

• Encourage and recognize the professional performance and development of all levels of staff.

• Think independently and possess critical thinking skills to accurately identify training needs within the department.

• Periodically conduct knowledge checks on training completed to ensure understanding by teammates and develop remediation training plans as needed.


Experience & Education:


• Bachelor's degree in Nursing or related field required.

• Current and unrestricted California Board Registered Nurse (RN) license required.

• 5 years of experience in clinical nursing and/or managed care required.

• 3 years of experience training in UM concepts and principles required.

• Experience in concurrent review or prior authorization or monitoring processes required.


Preferred Qualifications:


• Supervisory or lead experience preferred.

• Experience within managed care/utilization management preferred.


Knowledge of:


• Departmental procedures, policies, and clinical guidelines relative to utilization management and the authorization process.

• Principles and practices of managed health care.

• Appropriate strategies to serve diverse social and ethnic groups.

• Principles for effective training and development of training plans and calendars preferred.

• Medi-Cal, Medicare, Whole Child Model, Special Needs Plans and Cal MediConnect program guidelines.

• Benefit interpretation and administration of appropriate medical necessity guidelines.


Department(s): Utilization Management

Reports to: Director, Utilization Management

FLSA status: Non-Exempt

Salary Grade: M - $40.87 - $63.99 ($85,000 - $133,100)


CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.


If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California


Position Type:


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Clinical Trainer (Utilization Management)

Orange, CA
Full Time

Published on 07/19/2022

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