Clinical Quality Specialist

About the company

The organization is focused on building a single, connected mental health experience that supports people across therapy, medication management, meditation, and mindfulness. Its clinicians use digital tools and research-informed practices to improve care quality and help providers run strong, sustainable practices.

Team members are also expected to use modern AI tools in their daily work and stay adaptable as new technologies emerge. Comfort with job-relevant AI platforms such as Gemini, ChatGPT, Claude, GitHub Copilot, or similar productivity tools is considered an important part of success in the role.

Role overview

The Clinical Quality Specialist, Utilization Management role is designed to protect the clinical quality and compliance of care across the organization. The focus is on utilization management, payor-facing clinical audits, and quality assurance to ensure that care is medically appropriate, well documented, and aligned with evidence-based standards and payer expectations.

This is a collaborative position that supports providers while applying strong clinical judgment, audit readiness, and utilization review discipline. The role acts as a link between direct care, payer requirements, and internal quality benchmarks.

Key responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews to evaluate medical necessity, treatment fit, and level of care.
• Use evidence-based utilization management criteria to assess clinical documentation and support authorization and appeal workflows.
• Review care intensity and utilization patterns to spot unusual trends and guide targeted provider support.
• Work with health plans on external utilization review requests and coordinate peer-to-peer reviews.
• Look into provider concerns that arise from utilization findings, client complaints, or outside reports, and help resolve them.
• Track clinical adverse events and contribute to early risk mitigation with cross-functional partners.
• Support measurement-based care efforts and identify ways to improve outcomes across the provider network.
• Monitor utilization metrics, review volume, and case results to inform quality improvement work.
• Share patterns and workflow gaps with leadership and help improve utilization management policies and processes.

What success looks like

• Reviews are completed accurately, on schedule, and in line with payer and regulatory expectations.
• Utilization findings lead to clear provider support plans and measurable gains in care appropriateness.
• Cases are handled independently with strong clinical reasoning, complete documentation, and limited supervision.
• Cross-functional teams view you as a dependable, solutions-focused partner for quality and utilization issues.
• Provider relationships remain constructive and trust-based, even during remediation.
• You identify broader utilization trends and bring practical improvement ideas to leadership.

Required background

• Master’s degree in a mental health discipline.
• Active clinical license in good standing, such as LMFT, LPC, LCSW, LMHC, or an equivalent credential.
• Background in utilization management, utilization review, medical necessity review, or clinical auditing, preferably in behavioral health or a payer/health plan setting.
• Working knowledge of payer rules, medical necessity standards, and level-of-care guidelines.
• Strong clinical judgment and experience managing escalations, adverse events, or quality investigations.
• Ability to create clear, accurate, and defensible clinical documentation.
• Proven ability to collaborate effectively across different teams.
• Commitment to supporting providers while maintaining quality standards.
• Comfort using clinical technology tools for documentation, case tracking, and data analysis.

Benefits and perks

• At least three weeks of PTO per year.
• Holiday schedule aligned with standard U.S. holidays.
• Free therapy coverage for employees enrolled in a qualifying medical plan.
• Medical, dental, and vision coverage, including HSA and FSA options.
• HSA employer contribution of $1,100.
• Employer-paid short-term disability, long-term disability, life insurance, and AD&D coverage.
• Salary continuation for up to seven weeks of short-term disability leave after the required waiting period.
• Eight weeks of paid parental leave, with a total of 8–16 weeks possible if STD also applies.
• 401(k) plan with 100% match on up to 4% of base salary, vested immediately.
• Annual company gathering with teammates from across the country.
• Company shutdown between Christmas and New Year’s.
• Supplemental life insurance, pet insurance, commuter benefits, and additional offerings.

Application and equal opportunity

This role is being recruited on an ongoing basis and will remain open until it is filled.

The employer provides equal employment opportunities and does not discriminate on the basis of race, color, creed, sex, gender, gender identity or expression, pregnancy, childbirth or related medical conditions, religion, veteran or military status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition including genetic information or characteristics, sexual orientation, or any other status protected by law.