Quality Improvement Specialist

CARECOLLAB•New York, NY

15d•$75,000 - $90,000

About The Position

We are seeking a Quality Improvement & Compliance Specialist to lead quality assurance, compliance, and continuous improvement across our Health Home programs. This role will oversee chart auditing, pre-bill quality review, enrollment and care management documentation, corrective action, and quality reporting. The ideal candidate understands New York Medicaid Health Home requirements and can translate audit findings into sustainable processes and controls. This is a hands-on role for someone who is comfortable identifying risks, challenging findings when necessary, and partnering with clinical and operational leaders to improve quality and prevent recurring issues.

Requirements

3+ years of experience in New York Medicaid Health Home care management, either at a care management agency or Lead Health Home.
Hands-on experience with MAPP and a Health Home care management record system; FCM experience strongly preferred.
Experience conducting or responding to Lead Health Home chart audits.
Working knowledge of Health Home requirements related to enrollment, consent, appropriateness, diagnosis verification, core services, billing, diligent search, care plans, and continuity of care.
Comfortable holding a consistent quality standard, even when doing so requires challenging a colleague or leader.
Systems-oriented and focused on solving the root cause rather than repeatedly addressing the same issue.
Able to translate complex requirements into clear, practical expectations.
Strong written and verbal communicator who can turn findings into actionable recommendations.
Detail-oriented, analytical, and comfortable working independently.
Collaborative and constructive while maintaining appropriate independence and accountability.

Nice To Haves

Experience within a Lead Health Home quality or compliance function.
Familiarity with HH+, HARP, HCBS, and CORE requirements.
Quality improvement, compliance, or audit experience in Medicaid or another regulated healthcare environment.
RN, LMSW, LCSW, or related clinical background is a plus, but not required.

Responsibilities

Lead required quarterly Lead Health Home chart audits and conduct additional internal audits across care managers, supervisors, and programs.
Evaluate documentation against applicable Lead Health Home standards and identify trends, risks, and recurring findings.
Conduct pre-bill reviews to ensure member months are supported by appropriate services and documentation, including core services and diligent search requirements.
Hold or flag member months that do not meet applicable billing or documentation requirements and coordinate timely corrections.
Audit new enrollments for completeness, accuracy, eligibility, consent, diagnosis verification, and other required documentation.
Review care management documentation, including assessments, care plans, care plan tasks, member needs, required services, transitional care, and continued eligibility.
Monitor quality performance and produce monthly reporting on audit results, billing holds, corrective actions, and trends.
Partner with supervisors and department leaders to address quality issues and ensure corrective actions are implemented.
Turn recurring findings into sustainable controls, such as checklists, required fields, supervisor reviews, reports, and workflow improvements.
Maintain quality workflows and internal guidance as Lead Health Home and New York State requirements evolve.
Coordinate Performance Improvement Plan activities, claims lookbacks, and other corrective action initiatives.
Serve as an internal subject matter expert on Health Home quality, documentation, and compliance requirements.
Develop and deliver training based on audit findings and emerging quality trends.
Escalate significant or unresolved compliance concerns to executive leadership.
Hold a member month from billing when documentation does not support the claim.
Require documentation corrections before a case moves forward.
Audit records across teams and programs as needed.
Escalate unresolved compliance concerns to executive leadership.