Job Description

We are seeking a detail-oriented and highly organized

Quality Assurance (QA) Specialist

to join our behavioral health team. The primary responsibility of this role is to conduct thorough chart audits to ensure clinical documentation meets regulatory, accreditation, and internal quality standards. The QA Specialist plays a critical role in supporting clinical excellence, compliance, and continuous improvement across the organization.

The ideal candidate will also demonstrate a strong ability to review clinical notes to ensure they are accurate, complete, and aligned with documentation standards.

Key Responsibilities:

Conduct regular and ad hoc clinical chart audits to assess completeness, accuracy, timeliness, and compliance with internal policies, payer guidelines, and regulatory standards (e.g., CMS, Joint Commission, state requirements). Identify documentation gaps, discrepancies, and trends in clinical records and provide constructive feedback to providers and clinical teams. Ensure presence of

golden thread

throughout the charts as evidenced by connection from assessment to treatment planning and through ongoing progress notes.

Review clinical notes thoroughly to ensure they are written clearly, professionally, and meet established documentation standards.

Collaborate with clinicians, supervisors, and leadership to ensure proper follow-up on identified deficiencies. Maintain audit tracking systems, logs, and reports to monitor performance and improvement over time. Participate in the development and revision of audit tools, QA protocols, and documentation standards. Assist with preparation for external audits, surveys, or accreditation reviews. Support quality improvement initiatives by sharing audit findings, participating in team huddles, and recommending training or process changes as needed. Stay up to date on industry standards and regulatory changes related to behavioral health documentation and quality assurance.

Qualifications:

Bachelor's degree or higher in a behavioral health-related field, Health Information Management, Nursing, or a related discipline (required). 2+ years of experience in behavioral health or healthcare quality assurance, compliance, or medical records (required). Strong knowledge of clinical documentation standards, behavioral health terminology, and relevant regulations. Experience performing clinical chart audits or documentation reviews (required). Proven ability to review and evaluate the

quality and appropriateness of clinical notes

. Familiarity with EHR systems and the ability to navigate, extract, and evaluate records efficiently. Excellent attention to detail and organizational skills. Strong communication skills, with the ability to provide clear, respectful, and educational feedback. Ability to work independently, manage priorities, and maintain confidentiality.

Preferred Qualifications:

Certification in healthcare quality, compliance, or health information management (e.g., CPHQ, RHIT, RHIA, or CPC). Experience working with Medicaid/Medicare documentation standards or payer-specific audit requirements. Familiarity with quality improvement methodologies (e.g., Plan-Do-Study-Act cycles, Lean, Six Sigma).
Job Type: Full-time

Pay: ?30,000.00 - ?40,000.00 per month

Benefits:

Work from home
Schedule:

Monday to Friday Night shift
Experience:

working with night shift: 1 year (Required) performing clinical chart audits: 2 years (Required) EHR systems: 2 years (Required)
Work Location: Remote