Quality Assurance Clinician

## Description **POSITION SUMMARY** The Quality Assurance Clinician will serve as an integral member of our healthcare team, responsible for monitoring and enhancing service provision to ensure services are effective, efficient, and aligned with evidence-based standards of care. This position conducts comprehensive utilization reviews, quality reviews, and fidelity reviews for specialized programs including Individual Placement and Support (IPS) and Assertive Community Treatment (ACT). The Quality Assurance Clinician monitors medical record documentation for quality, appropriateness of care, managing level of care data to ensure service provision is consistent with individual needs, and appropriateness of services billed according to criteria, requirements, and guidelines established by payers and the agency. The Quality Assurance Clinician follows up on compliance results identified through review processes, leading improvement efforts, which includes providing training to staff on documentation standards and medical necessity. This position works collaboratively with quality and finance staff to ensure that documentation meets all requirements of payer sources (e.g., Medicaid/Medicare) and those specified within agency contracts, licensure, certification, and accreditation. The ideal candidate for the Quality Assurance Clinician position will possess strong clinical and documentation skills, attention to detail, exceptional organization, and a deep understanding of documentation and regulatory compliance requirements. This position requires the ability to effectively coordinate with multiple departments and external agencies, while fostering a culture of compliance and continuous quality improvement within the agency. **ESSENTIAL FUNCTIONS** - Review clinical documentation for completeness, timeliness, and adherence to regulatory standards and agency policies - Conduct utilization reviews to determine medical necessity, monitor service utilization patterns, and ensure appropriate allocation of resources - Perform quality reviews of clinical services and documentation to ensure adherence to established standards and best practices - Complete reviews/audits of clinical documentation that arise through the normal course of compliance plan monitoring - Follow up on compliance results to address identified deficiencies and ensure corrective actions are implemented - Manage level of care data to ensure service provision aligns with level of care and follow up on individuals whose service provision is not consistent with their level of care - Coordinate and collaborate with treatment teams to ensure the most appropriate service delivery for individuals served. This will include working with treatment providers of individuals that are high utilizers of services with minimal improvement in symptomology to ensure appropriate service provision. - Audit agency policies, procedures, and documentation to ensure fidelity to Evidence Based Practices (EBPs). This will include conducting fidelity reviews for Individual Placement and Support (IPS) and Assertive Community Treatment (ACT) programs to ensure adherence to evidence-based practice models. - Communicate with staff and supervisors around review findings - Collaborate with staff and supervisors to address documentation deficiencies - Work collaboratively with Managed Care Organizations (MCOs) and other insurance companies to ensure approval of medically necessary services for individuals served - Coordinate with Medical Records around audit and appeal requests - Appeal service denials, when appropriate - Coordinate follow up with agency providers and payers, as necessary - Utilize and contribute to clinical supervision processes to strengthen and maintain practice outcomes - Provide guidance to clinical teams regarding documentation and clinical best practice - Collaborate with the training department and Risk Management around training - Provide training on documentation standards an…