Clinical Quality Specialist

About the role

The Clinical Quality Specialist, Utilization Management role exists to safeguard and strengthen the clinical integrity of care delivered across the organization, with a focused lens on utilization management, payor-facing clinical audits, and clinical quality assurance. This position ensures that care is medically necessary, appropriately documented, and aligned with evidence-based standards and payor requirements supporting both provider success and defensible, compliant clinical operations. This is a collaborative, provider-supportive role that combines sound clinical judgment with the rigor of utilization review and audit-readiness. The Specialist serves as a key bridge between clinical care, payor expectations, and internal quality standards.

Responsibilities

• Utilization Management & Review
• Conduct prospective, concurrent, and retrospective utilization reviews to assess medical necessity, treatment appropriateness, and level of care
• Apply evidence-based UM criteria to evaluate clinical documentation and support authorization and appeal processes
• Monitor care intensity and utilization trends to identify outliers and inform targeted provider interventions
• Partner with health plans on external UR requests and peer-to-peer review coordination
• Clinical Quality & Provider Support
• Investigate and remediate provider concerns stemming from UM findings, client complaints, or external reports
• Monitor clinical adverse events and apply early-stage risk mitigation in partnership with cross-functional teams
• Support measurement-based care initiatives and identify opportunities to strengthen clinical outcomes across the provider network
• Reporting & Continuous Improvement
• Track utilization metrics, review volumes, and case outcomes to inform quality improvement efforts
• Surface trends and process gaps to leadership and contribute to the ongoing refinement of UM policies and workflows
• What does success look like?
• Utilization reviews are completed accurately, on time, and in compliance with payer and regulatory requirements
• UM findings translate into actionable provider support plans and measurable improvement in care appropriateness
• Cases are managed independently with sound clinical reasoning, thorough documentation, and minimal oversight
• Cross-functional partners rely on you as a knowledgeable, solutions-oriented collaborator on UM and quality matters
• Provider relationships remain trust-based and constructive, even through remediation processes
• You proactively identify systemic utilization trends and bring improvement recommendations to leadership

Requirements

• Master's degree in a mental health discipline.
• Active, cleared clinical license (e.g., LMFT, LPC, LCSW, LMHC, or equivalent) in good standing.
• Experience in utilization management, utilization review, medical necessity review, or clinical auditing - ideally in a behavioral health or payor/health plan context.
• Familiarity with payor requirements, medical necessity criteria, and level-of-care guidelines.
• Strong clinical judgment and experience handling escalations, adverse events, or quality-related investigations.
• Demonstrated ability to produce clear, accurate, and defensible clinical documentation.
• Demonstrated ability to collaborate effectively across multiple teams.
• Commitment to provider support and quality management.
• Familiarity with clinical technology platforms for documentation, case tracking, and data analysis to support provider quality and compliance.

Benefits

Additional Information

About SonderMind At SonderMind, we believe everyone deserves one personalized, connected, and effective mental health destination to take care of their mental health and well-being at any stage of life. SonderMind care encompasses everything from therapy and medication management to meditation and mindfulness exercises. Our clinicians leverage our digital tools and research to deliver increasingly high-quality care and to develop thriving practices. Combining technology and human connection, SonderMind drives better outcomes through our comprehensive approach. Learn more about SonderMind at sondermind.com or download the mobile app, available on iOS and Android. To follow the latest SonderMind news, get to know our clients, and learn about what it's like to work at SonderMind, you can follow us on Instagram , Linkedin , and Twitter . Additionally, we expect all team members to effectively leverage modern AI technologies as part of their everyday workflow, and to continuously adapt as new tools emerge. Familiarity with job-relevant AI platforms such as Gemini, ChatGPT, Claude, GitHub Copilot or other industry-standard AI productivity tools is expected and considered essential for success at this company.

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