Clinical Chart Auditor

AHG MASTER•Palm Springs, FL

1d•Onsite

About The Position

We are seeking a detail-oriented and knowledgeable Clinical Chart Auditor to support the integrity, quality, and compliance of documentation within our Behavioral Health Program. This role is responsible for reviewing clinical records to ensure documentation meets internal standards, payer requirements, regulatory expectations, and applicable behavioral health guidelines. The ideal candidate has experience in behavioral health documentation, strong knowledge of medical necessity and compliance standards, and the ability to work collaboratively with clinical and leadership teams to improve documentation quality and reduce audit risk. The Clinical Chart Auditor will review behavioral health charts for completeness, accuracy, timeliness, and compliance with organizational, state, federal, and payer requirements. This includes evaluating assessments, treatment plans, progress notes, authorizations, discharge summaries, and other clinical documentation to confirm alignment with services provided and established standards of care. This role will identify documentation deficiencies, trends, and areas of risk, then communicate findings clearly to program leadership and clinical staff. The auditor will prepare audit reports, maintain audit tracking tools, and support corrective action planning when needed. The position may also assist with internal quality improvement initiatives, policy compliance reviews, readiness for external audits, and staff education related to best practices in clinical documentation. The Clinical Chart Auditor is expected to collaborate with therapists, case managers, psychiatrists, nurses, quality staff, and operations leaders to promote accurate documentation, improve chart compliance, and strengthen overall program performance.

Requirements

Bachelor’s degree in a relevant field such as social work, psychology, counseling, nursing, health information management, or healthcare administration. Equivalent combinations of education and relevant experience may also be considered.
At least 2-3 years’ experience in behavioral health, clinical documentation review, quality assurance, utilization review, compliance, or medical record auditing.
Strong understanding of behavioral health terminology, levels of care, treatment planning, progress note standards, and documentation supporting medical necessity.
Highly organized, analytical, and comfortable reviewing large volumes of documentation with a high degree of accuracy.
Strong written and verbal communication skills.
Proficiency in electronic health records and Microsoft Office or similar reporting tools.
Excellent critical thinking, attention to detail, sound judgment, and the ability to interpret documentation against clinical, regulatory, and payer expectations.
Ability to maintain confidentiality.
Ability to manage competing deadlines.
Ability to present findings in a constructive, professional manner.
Strong quality improvement mindset.
Ability to build positive working relationships with clinical teams.

Nice To Haves

Experience auditing documentation in community mental health, substance use treatment, outpatient behavioral health, intensive outpatient, partial hospitalization, or other specialty behavioral health settings.
Experience with Medicaid, Medicare, managed care documentation standards, Joint Commission, CARF, or state behavioral health regulations.
Clinical licensure or certification, such as LPC, LCSW, LMFT, LMHC, RN may be considered an asset depending on program needs.

Responsibilities

Review behavioral health charts for completeness, accuracy, timeliness, and compliance with organizational, state, federal, and payer requirements.
Evaluate assessments, treatment plans, progress notes, authorizations, discharge summaries, and other clinical documentation to confirm alignment with services provided and established standards of care.
Identify documentation deficiencies, trends, and areas of risk.
Communicate findings clearly to program leadership and clinical staff.
Prepare audit reports.
Maintain audit tracking tools.
Support corrective action planning when needed.
Assist with internal quality improvement initiatives.
Assist with policy compliance reviews.
Assist with readiness for external audits.
Assist with staff education related to best practices in clinical documentation.
Collaborate with therapists, case managers, psychiatrists, nurses, quality staff, and operations leaders to promote accurate documentation, improve chart compliance, and strengthen overall program performance.