Description
**Medical Mutual employees must submit their applications through MySource. **This is a remote-based role, and we are currently seeking candidates located in Ohio.
Sr. Clinical Training & Audit Specialist
Job Summary:
Develops and delivers training programs for clinical, administrative, and management staff while performing audits and data analysis to ensure regulatory and accreditation compliance. Identifies learning objectives, designs training content across multiple formats, and evaluates program effectiveness. Serves subject matter expert to leadership on training needs and compliance trends. Maintains current knowledge of industry practices to support staff competency, process improvement, and high-quality member and provider outcomes.
Responsibilities:
- Delivers training programs including new hire, systems/criteria, core competencies, and remedial/refresher training to clinical, administrative, and management staff.
- Gathers data from multiple systems, interprets metrics and analytics, and identifies trends, compliance levels, and gaps relative to auditing expectations and performance benchmarks.
- Identifies learning objectives and designs or selects training content using multiple delivery formats (eLearning, instructor-led, blended), incorporating educational materials, training aids, and evaluation tools.
- Defines measurable outcomes for training programs, evaluates training and location effectiveness, and conducts cost/benefit and impact analyses to ensure continuous improvement.
- Reviews clinical documentation and system data to apply appropriate clinical criteria, organizational policies, and regulatory/accreditation standards. Consistently ensures activities are completed within guidelines.
- Serves as a resource to managers, SMEs, and training staff to identify development needs and recommend solutions; stays current with emerging industry processes and best practices.
- Performs other duties as assigned.
Qualifications:
Education and Experience:
- Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
- Equivalent education and experience directly related to the role may substitute for a degree.
- 3 years of progressive experience in health plan operations, case management, or utilization review, including training and curriculum development responsibilities.
Professional Certification(s):
- Registered Nurse with current State of Ohio unrestricted license.
- Certification in Case Management, Training, Project Management or nationally recognized health care certification preferred.
Technical Skills and Knowledge:
- Strong understanding of clinical management programs, health insurance operations, delegation arrangements, benefit structures, member and provider contracts, and clinical criteria.
- Knowledge of NCQA standards, CMS regulations, and applicable regulatory and accreditation requirements, with the ability to interpret and apply them to operational processes.
- Intermediate skills in Microsoft Office (Excel, PowerPoint, Word, Outlook, Access). Experience with claims management systems, clinical operations platforms, and online learning authoring tools.
- Foundational understanding of adult learning principles. Demonstrated ability to translate business objectives into effective training strategies, developmental goals, and learning solutions.
- Condenses complex clinical/operational data into clear, precise insights; strong written and verbal communication skills; and capability to adapt in a fast‑paced, dynamic environment.
Sr. Clinical Training & Audit Specialist
Job Summary:
Assesses training needs and develops learning solutions for clinical, administrative, and management staff. Develops, delivers, and evaluates cross-functional training programs, including onboarding, systems training, and quality improvement initiatives. Serves as an SME supporting operational excellence, regulatory compliance, and staff development. Analyzes training and audit data to drive continuous improvement.
Responsibilities:
- Leads complex training development and delivery by organizing department initiatives and facilitating advanced training programs—including new hire, systems/criteria, core competencies, and remedial/refresher courses—for clinical, administrative, and management staff, ensuring alignment with divisional needs.
- Designs and implements learning solutions across multiple formats to meet learning objectives and support diverse learning needs.
- Conducts advanced analytical reviews of training and audit performance by defining measurable outcomes, evaluating program effectiveness, performing cost/benefit analyses, interpreting audit results, and recommending continuous improvements based on trend and impact assessments.
- Partners with managers, SMEs, and training staff to assess development needs, implement targeted learning solutions, and provide coaching and mentorship on training and audit practices.
- Performs complex needs assessments and develops specialized training by conducting in depth analyses of clinical staff requirements, audit findings, and regulatory expectations, and translating them into effective classroom and online training programs that strengthen competency and compliance.
- Maintains expert level knowledge of clinical, regulatory, and industry trends by staying current with emerging best practices, technologies, CMS/NCQA standards, and process innovations, and proactively sharing insights with leadership to enhance departmental strategies and training/audit effectiveness.
- Performs other duties as assigned.
Qualifications:
Education and Experience:
- Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's degree preferred.
- 5+ years of progressive experience in health plan operations, case management, or utilization review, including training and curriculum development responsibilities.
- Equivalent education and experience directly related to the role may substitute for a degree.
Professional Certification(s):
- Registered Nurse with current State of Ohio unrestricted license.
- Certification in case management, training, project management, healthcare, or process improvement (e.g., CPTM, CPMA, Lean Six Sigma) preferred.
Technical Skills and Knowledge:
- Comprehensive knowledge of clinical management programs and health plan operations.
- Knowledge of NCQA standards, CMS regulations, and regulatory and accreditation requirements, with the ability to apply them to operations.
- Advanced Microsoft Office, claims management and/or clinical operations systems and online learning authoring skills.
- Advanced knowledge of instructional design and adult learning principles.
- Ability to translate business objectives into development goals, client solutions, and effective training programs.
Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:
- We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
- Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
- On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
- Discounts at many places in and around town, just for being a Medical Mutual team member.
- The opportunity to earn cash rewards for shopping with our customers.
- Business casual attire, including jeans.
Excellent Benefits and Compensation:
- Employee bonus program.
- 401(k) with company match up to 4% and an additional company contribution.
- Health Savings Account with a company matching contribution.
- Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
- Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
- Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
- After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.
An Investment in You:
- Career development programs and classes.
- Mentoring and coaching to help you advance in your career.
- Tuition reimbursement up to $5,250 per year, the IRS maximum.
- Diverse, inclusive and welcoming culture with Business Resource Groups.
About Medical Mutual:
Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.
#LI-CS1 #LI-REMOTE
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