Clinical Quality & Documentation Lead Job

Hopebridge, LLC•Indianapolis, IN

47d

About The Position

The Clinical Quality & Documentation Lead plays a pivotal role in maintaining excellence across all clinical services by ensuring accuracy, compliance, and integrity in documentation and reporting. This position combines direct clinical service with leadership in quality assurance, coaching, and documentation improvement. The Lead collaborates with clinicians and leadership to uphold best practices in psychological assessment, report writing, and payer compliance while fostering a culture of accountability and continuous learning. The role includes a billable clinical caseload-primarily focused on autism diagnostic assessments-with the opportunity to expand to additional clinical services as the department evolves. This position is ideal for a licensed psychologist who is detail-oriented, quality-driven, and passionate about advancing both clinical processes and professional practice standards through mentorship, collaboration, and integrity. Role Composition: 60% Billable Clinical Work 20% Quality Assurance & Documentation Leadership 10% Clinical Administrative Support

Requirements

Doctoral degree (PhD or PsyD) in Psychology from an accredited program.
Active, unrestricted psychologist license (or license-eligible within the required timeframe), PsyPact license preferred
Extensive experience in psychological assessment and report writing, particularly autism diagnostics.
Strong understanding of documentation requirements, payer standards, and clinical compliance.
Prior experience reviewing or mentoring clinical documentation preferred.
Familiarity with testing platforms (e.g., QGlobal, WPS) and electronic health record systems.
Ability to balance clinical productivity with quality oversight responsibilities.
Attention to Detail: Accurately identifies documentation gaps, inconsistencies, and errors.
Clinical Expertise: Strong diagnostic and assessment skills, particularly in autism evaluations.
Coaching & Feedback: Provides constructive, actionable feedback in a supportive manner.
Quality & Compliance Orientation: Deep understanding of payer requirements and documentation standards.
Analytical Thinking: Identifies systemic issues and contributes to process improvements.
Communication: Clear, professional written and verbal communication; able to explain complex requirements simply.
Collaboration: Works effectively with leadership, training teams, and clinicians.
Organization & Time Management: Balances audits, clinical work, and administrative responsibilities efficiently.
Must be in good standing within the department, including:
Meeting productivity and documentation timeliness expectations.
Minimal report errors or denials.
Positive family and peer feedback.
Demonstrated collaboration and engagement within the clinical team.

Responsibilities

Clinical Service Delivery (60%)
Conduct autism diagnostic evaluations using protocol set by organization (e.g., appropriate autism-specific, cognitive, adaptive, and broad symptom screener measures).
Provide additional billable clinical services as assigned or aligned with departmental needs.
Maintain accurate, timely documentation consistent with organizational and payer standards.
Meet established productivity goals while ensuring exceptional clinical quality and compliance.
Quality Assurance & Documentation Leadership (20%) - Quality Assurance and Review
Conduct quarterly audits of diagnostic reports, session notes, and related documentation.
Complete monthly follow-up audits to monitor progress and identify ongoing needs.
Analyze documentation patterns, providing individualized coaching and feedback to clinicians.
Maintain an audit tracker and summarize findings for leadership review.
Support insurance denial responses and ensure documentation aligns with payer requirements.
Collaborate with the Director to refine report templates, rubrics, and documentation standards.
Participate in state or organizational quality meetings as needed.
Quality Assurance & Documentation Leadership (20%) - Compliance and Corrective Action
Oversee timely resolution of documentation errors and corrective actions.
Support clinicians in implementing feedback and addressing denials.
Contribute to the development and monitoring of Performance Improvement Plans (PIPs) when documentation concerns arise.
Clinical Administrative Support (10%)
Participate in weekly departmental meetings and share quality-related updates.
Complete administrative tasks related to quality assurance, communication, and clinical operations.
Assist in workflow improvement initiatives and documentation process refinements.
Clinical Consultation & Support
Provide consultation on complex diagnostic or documentation cases, offering guidance on clinical formulation, report clarity, and best practices.
Review treatment recommendations for accuracy, clinical appropriateness, and adherence to standards.
Serve as a resource on ethical documentation, record-keeping, and compliance expectations.
Collaboration & Training
Partner closely with the Clinical Training & Onboarding Lead to integrate audit findings, documentation standards, and quality expectations into onboarding and continuing education.
Present updates and training segments during team meetings and departmental education sessions.
Contribute to the development and dissemination of quality and compliance resources.