Billing Compliance/Documentation QA Specialist

Description

POSITION SUMMARY

Makes sure every billed service is backed by documentation that meets Medi-Cal, DHCS, and County standards, so claims hold up when audited or reconciled. Also owns the separate tracking and reporting of non-Medi-Cal services (ISL) under Exhibit D.

Essential Duties and Responsibilities

• Update and verify that all forms used in intake packets and all informing materials (for example, the Medi-Cal beneficiary handbook, the Notice of Privacy Practices, and grievance and appeal notices) are the current County and DHCS versions. Remove outdated versions from use.
• Audit a sample of progress notes, assessments, and care plans each month against SMHS documentation standards, CalAIM requirements, and County documentation manuals.
• Confirm required items are done and documented on time: the CANS, the PSC-35 (parent-completed), ASAM screening for clients with substance use needs, the HFW Decision Support Criteria steps, and signatures and credentials.
• Match documented services to claims, checking codes, units, and time, before and after billing. Flag any claims that need to be voided or corrected.
• Identify duplicate client records (MRNs) and send MRN duplication requests to HCA through IRIS. Track each request until it's resolved, so services, claims, and ISL data post to the correct client record.
• Give HFW and ICM staff and supervisors written feedback and correction requests, and track them until they're resolved.
• Train new hires and give refreshers on documentation and billing standards, in coordination with HR Training.
• Collect and submit Exhibit D ISL data (non-Medi-Cal services and Flexible Fund spending at the individual-client level), using only the ISL codes the County issues. Fix data errors within County deadlines.
• Help prepare the monthly programmatic report, including the client-to-staff ratios as of month-end.
• Track documentation and billing KPIs for the QA/QI program, and suggest fixes when standards are not being met.
• Help with County, State, and internal compliance audits, including corrective action plans.
• Report suspected billing irregularities to the Compliance Officer.

Requirements

Minimum Qualifications

• Bachelor's degree in health information management, social work, psychology, or a related field.
• At least 3 years of behavioral health documentation review, utilization review, or QA experience, preferably in Medi-Cal SMHS.
• Detailed knowledge of SMHS documentation requirements, CalAIM documentation redesign, and medical necessity and access criteria.
• Comfortable training and coaching clinicians and paraprofessional staff.

Preferred Qualifications

• RHIT, CPC, or CPMA certification, or a California license or registration (LCSW, LMFT, LPCC, or associate).
• Experience auditing documentation in myEvolv.
• Experience auditing Wraparound or FSP programs.
• Experience with Orange County HCA's documentation standards.

Required Trainings

Annual Provider Training, Annual Compliance Training, and HIPAA/42 CFR Part 2 training. County BHS New User Training if the person will enter data in the County billing system.

PHYSICAL REQUIREMENTS:

• Ability to drive a motor vehicle without restrictions, often in heavy traffic and frequently long distances (one hour or more).
• Senses of vision, hearing and smell sufficient to regularly operate a motor vehicle, to visualize threats in the environment and operate safely.
• Required to occasionally lift and carry 10-20 pounds.
• Regularly required to sit, stand, climb stairs (1 or more flights) and walk.
• Regularly required to sit and use computer in office settings.

EOE, INCLUDING DISABILITY/VETS

We are an equal opportunity employer and consider all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, medical condition, genetic information, marital status, veteran status, or any other protected characteristic under California law.

Management reserves the right to add, change, delete or rescind duties or responsibilities of positions within the job classification at any time.