The Utilization Management Clinical Trainer plays a vital role in onboarding and developing clinical staff to ensure high-quality, consistent, and compliant utilization review services. This position is responsible for designing and delivering training programs for new utilization review nurses and coordinators, as well as providing ongoing education and support to current team members. The Utilization Management Clinical Trainer also collaborates with other clinical trainers to create standardized training materials that support clinical consistency across roles at Alignment. In addition to leading training initiatives, the Utilization Management Clinical Trainer contributes to utilization review audits and interrater reliability (IRR) assessments to promote ac-curacy, quality, and alignment with internal policies, accreditation standards, and regulatory guidelines. This position enhances reviewer confidence, ensures peer alignment, and encourages a culture of continuous learning, which are essential elements in developing a high-performing clinical team.

This position builds and maintains strong collaborative partnerships with key partners in the Clinical Services organization including Care Management, Performance Improvement, Medical Management and Policy including Quality and Medical Review and Appeals, Pharmacy, and Provider Integration to identify, develop, implement, and monitor performance metrics related to UM Operations.

This position also builds strong collaborative partnerships internally and externally with key stakeholders and vendors to ensure that internal and external UM operations programs are well-coordinated and work cooperatively to achieve outcomes goals. Areas of direct responsibility include Medical Utilization Management including Inpatient Review & Prior Authorization, SNF concurrent review, and pre-service authorization process.

This position is primarily remote; however, in-person attendance at Alignment Health's headquarters in Orange, CA is required approximately once per quarter for leadership meetings and team collaboration. Candidates located outside of California should expect periodic travel to the Orange office. Travel expenses are reimbursed in accordance with company policy.

Job Duties/Responsibilities:

Training and Onboarding

• Develop and implement onboarding and training programs for new staff in the utilization review process
• Create and maintain utilization review clinical training materials, quick-reference guides, and job aids that reflect up-to-date policies, processes, and review criteria to reflect changes in workflows, tools, and compliance requirements
• Design utilization review and other clinical training content to support standardized workflows used by all clinical reviewers, ensuring clarity and consistency across the clinical teams
• Collaborate with all trainers (clinical and non-clinical) to ensure consistency in approach and style across the organization
• Deliver engaging, practical education using real-world examples and case studies
• Design and deliver training for new processes, tools or platforms to ensure confident adoption and effective daily use
• Adapts training to reflect evolving regulatory environments, including state-specific utilization review requirements and client-specific clinical policies

Audit & Interrater Reliability (IRR)

• Participate in routine and targeted audits of medical necessity reviews to ensure quality, compliance, and appropriate clinical decision-making
• Collaborate with the Compliance Officer to conduct interrater reliability assessments to ensure consistency among reviewers
• Identify trends, gaps, or performance issues through audit and IRR results, and develop targeted training to address findings
• Assists the compliance officer with tracking and reporting on training completion, clinical quality improvements, and IRR improvements over time
• Support leadership in maintaining compliance with compliance standards and other applicable guidelines

Team Support & Collaboration

• Serve as a resource for clinical staff, offering guidance on accessing and interpreting clinical protocols, documentation practices, and decision-making frameworks
• Collaborate with clinical leadership to identify training needs and support operational goals
• Ensure consistency in training documentation across all clinical teams, including those supporting physician review
• Promote a positive, engaged team culture that reflects ICM's values of kindness, personal responsibility, humble confidence, and a can-do attitude
• Contributes to clinical team engagement by supporting professional development, building confidence in decision-making, and promoting a shared understanding of clinical expectations
• Other duties as assigned

Job Requirements:

Experience:

• Minimum of 5 years nursing experience in managed care, utilization review, case management, quality improvement, or acute care nursing-particularly roles involving interdisciplinary coordination, clinical documentation review, or patient discharge planning
• Experience developing and delivering clinical training preferred; candidates without formal training experience may still be considered if they demonstrate strong clinical communication skills and a passion for developing others
• Comfort with technology platforms used for clinical documentation, utilization review, and virtual training delivery

Education:

• Bachelor's degree in Nursing, Health or Education related field

Licensure:

• Active and unrestricted Registered Nurse (RN) or Licensed Practical/Vocational Nurse (LPN/LVN) license in good standing in the United States

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $77,905.00 - $116,858.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.