Quality Assurance Specialist

Ergii•Los Angeles, CA

6d•Remote

About The Position

The Quality Assurance Specialist works collaboratively with the Director of Quality Assurance, Vice President of Compliance and Operations, Utilization Review Department, Clinical Leadership, and Program Staff to ensure clinical and operational compliance across all programs. Responsibilities include program development and implementation, extensive quantitative and qualitative chart auditing, training staff on medical necessity and documentation standards, maintenance of policies and procedures, verification of billing documentation, and ensuring compliance with all applicable state, federal, accreditation, and regulatory requirements. The Quality Assurance Specialist plays a critical role in maintaining the integrity of client records, ensuring accurate documentation, supporting revenue cycle processes, and promoting compliance with organizational standards and regulatory requirements.

Requirements

Experience in behavioral health, substance use disorder treatment, mental health services, quality assurance, utilization review, or compliance preferred.
Advanced knowledge of the 12-Step treatment model and its application in residential treatment settings.
Knowledge of process addictions and available treatment resources.
Understanding of dual-diagnosis treatment practices and non-pharmacological symptom management techniques.
Advanced knowledge of HIPAA and 42 CFR Part 2 regulations.
Knowledge of medical necessity requirements and clinical documentation standards.
Familiarity with Joint Commission, CARF, and other accreditation standards.
Strong analytical, organizational, and problem-solving skills.
Excellent written and verbal communication skills.
Ability to work independently while maintaining collaboration with multidisciplinary teams.
Proficiency in electronic health record systems and Microsoft Office applications.
Current First Aid/CPR Certification.
Health Screening Clearance.
Ability to travel occasionally as required.

Responsibilities

Conduct comprehensive qualitative and quantitative chart audits to ensure compliance with organizational, payer, and regulatory requirements.
Audit clinical documentation to verify accuracy, completeness, timeliness, and compliance.
Monitor client charts daily to ensure all documentation supports the appropriate level of care and medical necessity.
Follow up with staff regarding deficiencies identified during audits and ensure corrective actions are completed within established timeframes.
Maintain audit records, corrective action plans, and compliance reports.
Develop, implement, and maintain quality assurance systems and checks-and-balances tools to ensure chart compliance.
Ensure services provided comply with: HIPAA regulations, 42 CFR Part 2 requirements, Joint Commission standards, CARF standards, ADP requirements, State and Federal regulations, Insurance and payer documentation requirements.
Assist with policy and procedure development, review, and maintenance.
Identify compliance risks and recommend corrective actions and process improvements.
Assist with training and education of Clinical and Support Staff regarding: Medical necessity documentation, Clinical documentation requirements, Regulatory compliance standards, Quality assurance processes.
Collaborate with Clinical Directors and Leadership Teams to provide coaching and documentation support.
Participate in onboarding and ongoing staff education initiatives as assigned.
Collaborate with the Utilization Review Department to ensure timely completion of clinical documentation.
Work with billing departments and contracted billing companies to verify documentation required for claims submission.
Ensure documentation supports services billed and complies with payer requirements.
Assist in resolving documentation-related billing issues.
Participate in program development and quality improvement initiatives.
Assist with regulatory audits, accreditation surveys, and compliance reviews.
Prepare reports and compliance metrics as requested.
Perform other duties as assigned by the Director of Quality Assurance, Vice President of Compliance and Operations, Clinical Director, or Executive Leadership.