Quality Assurance Specialist

Job Description

Job Description

SUMMARY OF POSITION

Reporting to the Sr. Director of Clinical Services and Program Innovation, the Quality Assurance Specialist is responsible for supporting the integrity, accuracy, compliance, and timely billing of Drug Medi-Cal (DMC) substance use disorder services provided by NCADD-SFV.

This position serves as a key quality control function between clinical service delivery, documentation, billing, and program operations. The Quality Assurance Specialist reviews clinical documentation and service data to verify that services submitted for reimbursement are supported by the patient record, appropriately documented, medically necessary, delivered by qualified staff, and compliant with applicable Los Angeles County Department of Public Health Substance Abuse Prevention and Control (SAPC), California Department of Health Care Services (DHCS), Medi-Cal, CalAIM, and organizational requirements.

The position requires hands-on experience with Los Angeles County DMC billing and documentation workflows, including Sage-PCNX or other applicable SAPC systems. The Quality Assurance Specialist conducts pre-billing reviews, identifies documentation and billing discrepancies, communicates corrections to clinical and administrative staff, tracks resolution of identified issues, and supports timely and accurate claims submission.

The Quality Assurance Specialist also conducts ongoing chart reviews, internal audits, utilization and documentation monitoring, and quality improvement activities. The position works collaboratively with clinical leadership, counselors, LPHA staff, administrative staff, Finance, and executive leadership to strengthen compliance and reduce organizational exposure to billing errors, disallowances, recoupments, fraud, waste, and abuse.

DUTIES AND RESPONSIBILITIES

1. DMC Billing Review and Validation

• Review DMC services prior to billing to verify that services are supported by complete and compliant documentation.

• Validate service dates, service types, duration, units, rendering providers, locations, and other billing information against the clinical record.

• Review services entered into Sage-PCNX and applicable electronic health record systems for accuracy and consistency.

• Identify duplicate services, overlapping services, unsupported units, missing documentation, incorrect service codes, and other billing discrepancies.

• Verify that services submitted for reimbursement were actually rendered and appropriately documented.

• Review documentation to ensure billed services are consistent with the patient's treatment needs and applicable medical necessity requirements.

• Verify that rendering practitioners possess the appropriate credentials, registration, certification, licensure, or scope of practice for services provided.

• Coordinate corrections with clinical and administrative staff prior to claim submission.

• Track outstanding billing corrections and follow through until discrepancies are appropriately resolved.

• Assist with denied, rejected, or otherwise problematic claims and identify recurring billing issues requiring corrective action.

2. Clinical Documentation Quality Assurance

• Conduct routine reviews of patient records for completeness, accuracy, timeliness, and regulatory compliance.

• Review assessments, problem lists, treatment and care planning documentation, progress notes, group documentation, discharge documentation, care coordination records, and other required clinical documentation.

• Evaluate whether documentation adequately supports the service provided and billed.

• Review documentation for consistency between the patient's identified needs, services provided, interventions, response to treatment, and ongoing plan of care.

• Identify missing signatures, incomplete documentation, incorrect dates, inconsistent information, and other documentation deficiencies.

• Communicate deficiencies clearly to responsible staff and establish timelines for correction when appropriate.

• Monitor correction of identified deficiencies and escalate unresolved or recurring concerns to clinical leadership.

• Support implementation of standardized documentation practices across NCADD-SFV clinical programs.

3. SAPC, DHCS, and Medi-Cal Compliance

• Maintain working knowledge of current SAPC Provider Manual requirements, DHCS DMC requirements, Medi-Cal policies, CalAIM documentation standards, applicable Title 9 requirements, and other relevant regulatory guidance.

• Monitor changes in county and state billing and documentation requirements and assist leadership with operational implementation.

• Ensure quality assurance activities align with SAPC, DHCS, CARF, contractual, and organizational requirements.

• Assist with preparation for SAPC, DHCS, CARF, Medi-Cal, fiscal, and other external audits or monitoring activities.

• Support responses to audit findings, corrective action plans, and requests for supporting documentation.

• Maintain organized records of internal reviews, findings, corrective actions, and follow-up activities.

4. Internal Auditing and Compliance Monitoring

• Conduct routine and targeted internal audits of clinical records and billed services.

• Perform retrospective reviews when billing, documentation, utilization, or compliance concerns are identified.

• Compare billed services against supporting clinical documentation and applicable source records.

• Identify trends or patterns that may indicate systemic documentation or billing weaknesses.

• Immediately escalate potentially unsupported, inaccurate, duplicate, falsified, or otherwise questionable billing to appropriate leadership.

• Assist in determining the scope and financial impact of identified billing discrepancies.

• Support processes for voiding, correcting, replacing, or otherwise resolving claims when errors are confirmed.

• Maintain confidentiality and objectivity when conducting compliance reviews or investigations.

• Support organizational efforts to prevent and detect fraud, waste, abuse, and improper billing.

5. Utilization and Service Monitoring

• Monitor service utilization and documentation patterns for consistency with program requirements and patient needs.

• Review productivity and billing reports for unusual patterns, outliers, or inconsistencies requiring additional review.

• Assist leadership in analyzing service volume, utilization, documentation completion, and billing performance.

• Support monitoring of timely access, admission, continued services, transitions between levels of care, and discharge processes when applicable.

• Collaborate with clinical leadership regarding patterns that may indicate training, supervision, workflow, or compliance concerns.

6. Quality Improvement

• Track quality assurance findings and develop reports identifying recurring deficiencies, trends, and opportunities for improvement.

• Participate in Performance Improvement and quality management activities.

• Recommend workflow improvements designed to strengthen documentation quality, billing accuracy, and regulatory compliance.

• Assist in developing QA tools, audit instruments, checklists, monitoring reports, and standardized workflows.

• Participate in corrective action planning and monitor progress toward identified improvement goals.

• Assist leadership in developing measurable quality indicators related to documentation, billing, compliance, and service delivery.

7. Training and Technical Assistance

• Provide technical assistance to clinical and administrative staff regarding DMC documentation and billing requirements.

• Assist with orientation and training of new staff regarding documentation standards, billing workflows, Sage-PCNX, and quality assurance expectations.

• Provide individualized feedback to staff regarding identified documentation or billing deficiencies.

• Collaborate with supervisors to identify recurring training needs.

• Assist with agency-wide training regarding documentation integrity, medical necessity, billing compliance, and fraud, waste, and abuse prevention.

• Promote a culture in which documentation accurately reflects services actually delivered to patients.

8. Collaboration and Communication

• Work collaboratively with clinical leadership, counselors, LPHA staff, administrative staff, Finance, and executive leadership.

• Communicate QA findings objectively, professionally, and in a manner that supports timely corrective action.

• Participate in clinical, administrative, QA, compliance, and operational meetings as assigned.

• Serve as a resource to staff regarding DMC billing and documentation questions.

• Maintain appropriate professional boundaries and confidentiality when reviewing patient, personnel, financial, or compliance information.

• Immediately report significant compliance concerns through established organizational reporting channels.