Clinical Quality Improvement Specialist

The Clinical QI & Investigative Specialist executes the clinical quality assurance, risk management, and investigative operations at Universal Support Agency (USA). This role ensures that all Mental Health Rehabilitation Services (MHRS) comply with DC Department of Behavioral Health (DBH) regulations, federal guidelines, and clinical best practice standards. The Specialist investigates critical incidents, resolves consumer grievances, audits clinical charts for medical necessity and diagnostic accuracy, and documents Corrective Action Plans (CAPs) to elevate the standard of care and mitigate organizational and regulatory risk. This role collaborates and reports to the Quality Improvement Director.

1. Investigations & Incident Management

• Lead investigations into Major Unusual Incidents (MUIs), critical incidents, sentinel events, consumer deaths, and allegations of abuse or neglect, applying clinical judgment to determine whether care met the standard of practice, and submitting findings and recommendations for internal leadership review.
• Conduct Root Cause Analyses (RCA) and Enhanced RCAs to trace adverse outcomes to their clinical or systemic root cause, escalating to the QI Director any findings that indicate a systemic, cross-provider, or organizational risk pattern (e.g., backdating trends, recurring diagnostic mismatch).
• Author investigative reports with documented findings, clinical conclusions, and actionable recommendations suitable for DBH, DHCF, or internal leadership review, in ccollaboration with the QI Director on final content and distribution.
• Manage clinical grievances, evaluating whether complaints about treatment, diagnosis, or care delivery have clinical merit, documenting resolution within DBH timeliness standards, and submitting clinical grievance resolutions to the QI Director for final documentation review prior to closure.
• Executes and monitor Corrective Action Plans (CAPs), addressing root clinical causes (e.g., scope-of-practice violations, diagnostic inconsistency, under-treatment), in collaboration with the QI Director.

2. Clinical Auditing & Quality Assurance

• Conduct routine medical necessity chart audits (e.g., CPT 90791, 90792, 99215, H0036) against DSM-5 criteria and CMS guidelines to verify medical necessity and clinical appropriateness of billed services, using quality improvement methodologies.
• Monthly review of diagnostic accuracy of clinical documentation to confirm diagnoses are clinically substantiated by presenting symptoms and assessment data, reporting findings for inclusion in departmental QI reporting.
• Facilitate Clinical Peer Review evaluating documentation quality, treatment plan soundness, and clinical decision-making across providers, in accordance with Peer Review policy and submitting session outcomes for departmental reporting.
• Track and clinically interpret utilization trends, interpreting drivers such as under-treatment, misdiagnosis, access to care timeliness, or wrong level of care, and briefing the QI Director and internal leadership on trends relevant to agency-wide performance reporting.

3. Regulatory Compliance & Training

• Collaborate with to Conduct agency-wide mandated training reinforce standards of care.
• Maintain current knowledge of changing DC local law, federal regulation, and DBH Chapter 34 policy updates, assessing operational impact on clinical practice and briefing the QI Director on any needed policy revisions.
• Serve as the Clinical lead in internal peer review, CAP follow up, reporting clinical risk findings to the QI Director.

Clinical & Regulatory

• Active, unrestricted DC clinical license: LGSW, LICSW, or LPC.
• Working knowledge of 22-A/22-B DCMR Chapter 34, DC Medicaid (DHCF) billing standards, and MHRS service definitions.
• Demonstrated experience with chart auditing, RCA methodology, and clinical documentation review.
• Strong investigative report writing with defensible, evidence-based findings.
• Ability to work independently and collaboratively with QI, HR, Program and Clinical leadership on sensitive personnel and compliance matters.

Technical & Communication Skills

• Advanced Microsoft Excel skills, developing pivot tables, formulas, and dashboards to track audit findings, performance thresholds, and trend data.
• Proficiency in Microsoft PowerPoint to build clear, professional presentations for multiple audience reporting.
• Strong Microsoft Word skills
• Excellent written and verbal communication skills, with the ability to communicate sensitive or adverse findings clearly, tactfully, and persuasively to staff, providers, and leadership.
• Strong interpersonal skills for cross-departmental collaboration and the judgment to know when to escalate versus resolve independently.

Required Credential

Active DC clinical license — LGSW, LICSW, or LPC (or equivalent independent/graduate clinical license)