Quality Assurance Specialist - Community Supports

Pacific Health Group•Cross Lanes, WV

1d•$27 - $33•Hybrid

About The Position

The Quality Assurance Specialist – Community Supports (CS) ensures documentation accuracy, compliance, and workflow integrity specifically across all CalAIM Community Supports service lines (such as Housing Transition/Tenancy, Medically Tailored Meals, Recuperative Care, and Environmental Adaptations). Serving as the subject matter expert on CS guidelines, this role audits member authorizations, service delivery documentation, billing/invoice integrity, and provider network compliance. This position strengthens operational integrity, ensures regulatory compliance with Managed Care Plans (MCPs) and DHCS guidelines, and drives continuous process improvement across CS workflows. The CS QA Specialist directly impacts claim approval rates, regulatory compliance, sub-recipient/CBO oversight, and overall quality of social care delivery.

Requirements

Bachelor’s degree in Healthcare Administration, Public Health, Social Work, Quality Management, or a related field.
2+ years of experience in quality assurance, compliance auditing, care coordination quality review, or healthcare program oversight.
Direct familiarity with CalAIM Community Supports (CS) service definitions, ECM, Medi-Cal guidelines, HIPAA, and Managed Care Plan audit requirements.
Proven ability to analyze complex healthcare/social service workflows and audit EMR/CRM documentation for compliance gaps.
Strong written, analytical, and interpersonal skills, with experience delivering constructive feedback and training to operational teams.
Proficiency with EMR/EHR platforms, CRM systems, and Microsoft Excel (data tracking, audit log management).
Valid Driver's License, active auto insurance, and reliable transportation required for 40% field visits and site audits.

Responsibilities

Conduct routine and targeted audits of Community Supports member files, authorization requests, and individual service plans to ensure alignment with CalAIM, DHCS, and Managed Care Plan standards.
Audit documentation for specific CS service lines (e.g., verifying proof of housing transition steps, meal delivery tracking, recuperative care length-of-stay logs, and home adaptation receipts).
Verify that member eligibility assessments, authorizations, and disenrollment workflows adhere to required timelines and regulatory mandates.
Ensure strict adherence to HIPAA guidelines, member consent protocols, and privacy standards across all CS platforms and external provider exchanges.
Evaluate CS intake, referral, authorization, and service delivery workflows for gaps, inefficiencies, and compliance risks.
Track error trends, documentation deficiencies, and billing/invoice discrepancies between internal care teams and external CS vendors.
Formulate Corrective Action Plans (CAPs) and lead process-improvement initiatives to resolve systemic documentation issues.
Monitor contracted Community Supports service providers and CBO partners to verify that delivered services match billed claims and documented care plans.
Collaborate with internal teams to ensure provider invoice reconciliations meet quality and compliance thresholds before submission to Managed Care Plans.
Track and maintain core CS quality metrics, including assessment timeliness, authorization pass rates, documentation accuracy, and audit scorecards.
Generate regular compliance reports for program leadership outlining error trends, risk areas, and audit findings.
Partner with CS Coordinators, ECM leads, and operational managers to provide feedback, direct coaching, and training based on audit findings.
Conduct community- and site-based outreach and auditing across target counties. This includes field-based audits of contracted Community Supports vendors/CBOs, evaluating physical compliance (e.g., housing or environmental modification standards), verifying member service delivery directly in the field, and conducting outreach to community partners to align quality standards. A minimum of 40% of this role is dedicated to direct community outreach.