Program Integrity Jobs in Durham, NC (NOW HIRING)

The UM Program Integrity Specialist is responsible for leading the development, implementation, maintenance, and continuous improvement of a comprehensive Utilization Management (UM) Training Plan that supports onboarding, role-specific education, ongoing competency development, and consistent application of UM workflows across administrative and clinical support functions. This role partners with UM leadership, the Clinical Education Team, subject matter experts, and other internal stakeholders to assess training needs, develop learning pathways, maintain training materials, support learning platform content, and evaluate training effectiveness.

In support of the UM Training Plan, the UM Program Integrity Specialist also assists with UM program documentation, policy and procedure maintenance, workflow and process integrity, MCG update readiness, audit and monitoring activities, and NCQA accreditation preparedness. The role promotes consistency, accountability, regulatory alignment, and operational sustainability across UM operations.

This position is full-time remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required. 

Responsibilities & Duties

UM Training Plan Development and Maintenance

• Lead the development, implementation, maintenance, and continuous improvement of a comprehensive UM Training Plan for administrative and clinical support roles within UM
• Conduct training needs assessments in partnership with UM leadership, the Clinical Education Team, subject matter experts, and operational stakeholders
• Develop role-based learning pathways, onboarding curricula, competency-based education, refresher training, and training plans related to UM workflows, systems, documentation expectations, and process changes
• Create, update, and organize training materials, job aids, desk references, learning resources, and educational content using adult learning principles
• Partner with the Clinical Education Team to support conversion of training content for delivery through Alliance University and other approved learning platforms
• Monitor training effectiveness through feedback, completion data, audit findings, competency trends, and leadership input; recommend improvements as needed

Training Coordination and Stakeholder Collaboration

• Coordinate with UM leadership to prioritize training needs related to onboarding, role transitions, workflow changes, policy updates, system changes, regulatory requirements, and identified performance or process gaps
• Facilitate or support delivery of UM training content, as assigned, in partnership with operational leaders, the Clinical Education Team, and UM subject matter experts
• Maintain communication with stakeholders to ensure training resources remain current, accessible, and aligned with department expectations
• Serve as a training resource for UM leadership and staff regarding training plans, learning pathways, job aids, LMS content, and training-related process questions

UM Program Documentation and Resource Development

• Support development and maintenance of UM program documentation, including policies, procedures, desk procedures, program descriptions, program evaluations, job aids, and related resources
• Collaborate with the UM Clinical Systems Analyst and other internal partners to ensure documentation aligns with operational workflows, training expectations, NCQA standards, contractual requirements, and regulatory requirements
• Maintain organized and accessible training and program resources that support consistent UM operations and staff competency
• Develop and update tools and templates that support training, documentation consistency, workflow clarity, and program integrity

Workflow System Change, and Process Integrity Support

• Collaborate with UM leadership and internal business partners to evaluate workflows, identify process gaps, and recommend improvements that strengthen consistency, role clarity, and operational efficiency
• Support MCG integration activities and annual upgrades by assisting with workflow alignment, testing support, documentation updates, communication planning, and staff education related to criteria or system changes
• Partner with operational, systems, clinical education, and subject matter expert teams to ensure workflow changes are reflected in training materials, job aids, procedures, and other program resources
• Serve as a resource to leadership regarding process integrity concerns, documentation gaps, training needs, and opportunities for standardization

Audit, Monitoring, and Training Effectiveness Support

• Conduct or support audits and monitoring activities related to UM documentation, process adherence, training effectiveness, competency indicators, and quality trends
• Summarize audit and monitoring findings for leadership and support identification of training opportunities, documentation updates, corrective actions, and process improvements
• Track trends from audits, training feedback, workflow issues, and operational updates to support continuous improvement of the UM Training Plan
• Report training, audit, and workflow outcomes to leadership and recommend improvements to strengthen consistency, compliance, and operational sustainability

Compliance, Accreditation, and Delegation Readiness Support

• Support accreditation readiness and audit preparedness by maintaining training and program documentation aligned with NCQA standards, contractual requirements, and regulatory expectations
• Collaborate with UM leadership, the Accreditation department, Clinical Informatics, and other internal stakeholders to support NCQA-related documentation, delegation oversight, and audit follow-up activities
• Serve as a resource for UM policies, procedures, documentation standards, training expectations, and regulatory alignment
• Ensure training materials and UM program resources are updated when accreditation, regulatory, contractual, policy, procedure, or operational requirements change

Minimum Requirements

Education & Experience

Required:

Bachelor’s degree in education, instructional design, training and development, organizational development, healthcare administration, public health, behavioral health, human services, nursing, social work, psychology, counseling, or a related healthcare, human services, or education field and five (5) years of experience developing, implementing, maintaining, or evaluating training programs, learning plans, onboarding curricula, competency-based education, staff development initiatives, or role-based learning pathways

Experience must include training needs assessment, curriculum development, training material design, stakeholder collaboration, facilitation or learning platform support, and evaluation of training effectiveness.

Preferred:

Master’s degree preferred in Education, Instructional Design, Training and Development, Organizational Development, Healthcare Administration, Public Health, Behavioral Health, Nursing, Social Work, Counseling, Psychology, or a related field.

Clinical licensure may be beneficial but is not required for this position.

Experience developing utilization management training plans or role-based learning pathways; working with learning management systems; applying adult learning principles; partnering with clinical, operational, education, accreditation, quality, compliance, or systems teams; maintaining training resources, job aids, policies, procedures, and program documentation; and supporting training related to UM workflows, NCQA accreditation standards, Medicaid managed care, MCG or comparable criteria platforms, audit/monitoring activities, policy and procedure changes, or process improvement initiatives is preferred.

Relevant certification or documented training in training and development, instructional design, healthcare quality, accreditation, compliance, utilization management, managed care operations, project management, process improvement, MCG, or NCQA standards. Examples include: CPTM, CPTD, APTD, CPHQ, CHC, CCEP, Lean Six Sigma Yellow Belt/Green Belt, PMP, CAPM, MCG training/certification, NCQA-related training, or comparable certification.

Knowledge, Skills, & Abilities

• Advanced knowledge of training program development, curriculum design, onboarding support, competency-based education, and adult learning principles.
• Ability to develop and maintain role-based learning pathways, training plans, job aids, desk references, and learning resources.
• Proficiency using virtual training tools, digital learning platforms, Microsoft Office, and learning management systems or comparable training platforms.
• Strong written communication skills, including the ability to translate complex workflows, policies, procedures, and regulatory expectations into clear training materials.
• Strong verbal communication, facilitation, collaboration, and stakeholder engagement skills. 
• Strong organizational, project coordination, prioritization, and follow-through skills.
• Strong analytical, evaluation, and critical thinking skills to assess training needs, identify gaps, evaluate outcomes, and recommend improvements.
• High level of professionalism, integrity, confidentiality, and sound judgment.
• Knowledge of utilization management operations, managed care, Medicaid, healthcare authorization workflows, and clinical or administrative UM documentation.
• Knowledge of NCQA accreditation standards, delegation oversight, audit readiness, quality monitoring, and regulatory requirements.
• Experience supporting policy, procedure, workflow, program description, program evaluation, or operational documentation development.
• Experience supporting process improvement, workflow standardization, monitoring tools, audit templates, or corrective action support.

Salary Range

$69,592 - $90,469/Annually