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 and medical necessity to ensure staff competency and compliance with regulatory requirements
• Develop and implement specialized training for aspects of clinical practice based upon trends identified through routine utilization and chart reviews and other continuous quality improvement initiatives
• Track and report on documentation quality metrics and compliance indicators, as appropriate

Other Duties:

• Demonstrate cultural and linguistic competence

• Approach interactions with individuals served and colleagues with a trauma sensitive lens

• Act as an ambassador of the agency in the community setting, which may include doing public educational and informational presentations

• Support and actively promote the vision and mission of the agency and the philosophy of the strengths perspective

• Complete required trainings

• Other duties as assigned, as qualified and trained for

POSITION QUALIFICATIONS

• Master’s degree in Psychology (LMLP, LCP), Counseling (LPC, LCPC), or Social Work (LMSW, LSCSW)

• Current Kansas Behavioral Science Regulatory Board license at the Master’s level or higher

• Two (2) years post graduate degree experience in the behavioral health field providing direct service

• Experience with ICD-10, CPT coding, and DSM-5 diagnostic criteria

• Three (3) to five (5) years’ experience working in a Community Mental Health Center (CMHC) or a Certified Behavioral Health Clinic (CCBHC) preferred

• Familiarity and the ability to work with Managed Care Organizations (MCOs) and other insurance companies preferred

• Knowledge of community based services preferred

• Experience in quality management in a healthcare setting preferred

• Familiarity with the Kansas Department of Aging and Disability Services’ (KDADS) licensing standards for mental health and alcohol and/or other drug abuse treatment programs and Certified Community Behavioral Health Clinic (CCBHC) certification criteria preferred

• Demonstrated experience with electronic medical record systems and health information technology

• Successful completion of Kansas Bureau of Investigation (KBI), Central Registry, and other applicable background investigations and possess a valid Kansas driver's license

KNOWLEDGE/SKILLS/ABILITIES

• Strong clinical skills

• Strong documentation skills

• Person/Family centered

• Ability to maintain confidentiality of business operations and clinical services

• Ability to foster a culture of compliance and continuous quality improvement

• Ability to work independently with minimum supervision

• Excellent organizational skills

• Attention to detail and accuracy in work

• Time management including the ability to prioritize issues/tasks

• Customer focused (internal and external)

• Professional and effective communication skills (verbally and written)

• Collaborative - Must work collaboratively with other team members to deliver optimal services

• Accountability

• Reliability

• Integrity

• Initiative

• Adaptability/Flexibility

• Problem solving/Good judgment

• Proficiency in Microsoft Office Suite (MS Office Word, Excel, and Outlook) with the ability to learn other software programs as necessary

• Open to learning and accepting feedback

PHYSICAL DEMANDS

N (Not Applicable) Activity is not applicable to this position.

O (Occasionally) Position requires this activity up to 33% of the time (0 – 2.5 hrs/day)

F (Frequently) Position requires this activity from 33% - 66% of the time (2.5 – 5.5 hrs/day)

C (Constantly) Position requires this activity more than 66% of the time (5.5 hrs/day)

Physical Demands Lift/Carry

Other Physical Requirements:

This position requires the ability to work independently. The job is largely sedentary. The position is required to regularly read and comprehend electronic information. Travel between agency locations is required, as needed.

SUPERVISORY RESPONSIBILITIES

This position has no direct supervisory responsibilities.

WORK ENVIRONMENT

Office-based working environment. Minimal risk of exposure to aggressive and/or acting out (verbal and physical) behaviors. This position may involve long periods of sitting or standing and using the computer. This position involves continual use of the keyboard and computer. Most interactions are with other agency staff or funding or regulatory agencies.