Req#: 2899203Job Type
Full-time
Description
SUMMARY:
Under supervision of the QA Supervisor, the Clinical QA Specialist II will conduct internal audits/review of client medical records and any other records that are related to the requirements set by the Medi-Cal funded programs and prepare internal reports detailing the audit findings. All audit and review work will be done using the electronic health record software. Specifically, the Clinical QA Specialist II is responsible for clinical documentation review, clinical auditing of client charts and timely completion of program chart audits. Also, the QA Specialist will provide ongoing chart evaluation for clinical cohesiveness and adherence to: Medi-Cal standards, contract compliance, HIPAA standards, client safety, professional ethical standards, as well as ensure that charts meet County of San Bernardino Medi-Cal standards/contract standards.
KNOWLEDGE, SKILLS & ABILITIES:
1. Thorough understanding of Medi-Cal documentation requirements.
2. Proficient with electronic health record software.
3. Must be proficient with Microsoft Word, Excel and Microsoft Outlook.
4. Must be able to communicate clearly, both verbally and in writing.
5. Must be able to author and produce their own emails, letters, reports and other documents in a
professional manner. That is, documents and correspondence should be relatively free of grammar
and spelling errors.
6. Ability to interact professionally and effectively with all levels of employees within the organization,
to include peers, co-workers and supervisors.
7. Must be detail oriented and have the ability to complete documentation in a timely manner.
8. Excellent time management, organizational and follow through skills.
9. Ability to appear to work every day and on time. Must have reliable transportation as travel up to 2
hours between office locations and within the community is required.
10. Ability to follow directions from a supervisor.
11. Ability to understand and follow posted, printed and/or electronic work rules and procedures.
12. Ability to accept constructive criticism in a respectful, open and interactive manner.
13. Experience working with people over the phone.
14. Must have the ability to perform efficiently and effectively with multiple interruptions.
JOB DUTIES & RESPONSIBILITIES:
1. Ensure accuracy, timeliness, thoroughness, and completeness of Medi-Cal documentation and other
documents.
2. Complete timely review of progress notes, assessments and other clinical documents.
3. Systematically coordinate and complete clinical audit of client charts. Use "Clinical Audit Tool Quality
Chart Review" audit protocol/audit program documents when auditing the clients' charts. Document
the results of reviews thoroughly and completely.
4. Report staff documentation deficits to the QA Supervisor whenever identified and verify that the deficits
are corrected in a timely manner by tracing the deficient notes.
5. Maintain audit tracking data base, monitor, and track areas for follow up.
6. Work with QA Supervisor to identify measures to monitor client satisfaction, client safety, quality of
services, client treatment outcomes (progress toward goals), and staff satisfaction.
7. Prepare and coordinate County audits in conjunction with the QA Supervisor.
8. Attend County meetings as requested by QA Supervisor only.
9. Participate in SCCS mandatory trainings, and external trainings as requested by QA Manager only.
10. Maintain accountability to all Law and Ethics and SCCS Policies and Procedures.
11. Provide information and complete reports as necessary
12. Assists with new hire documentation training as well as any requested trainings on an ongoing basis.
13. Performs other related duties as required and assigned.
Requirements
GENERAL REQUIREMENTS:
Education/Experience
1. Master's degree in related field preferred.
2. Significant experience with Electronic Medical Record/Electronic Health Record software required.
3. Experience with EMR preferred.
4. Must be proficient with CA MediCal documentation standards. Experience with San Bernardino, Orange,
and San Diego counties preferred.
Licensure, Registration, Certification
1. Registered with Board of Behavioral Sciences as LMFT, LCSW, LPCC or with Board of Psychology as
Licensed Registered Psychologist.
2. Valid CA driver's license and proof of automobile insurance.
3. Completion of CPR/First Aid certification within the first thirty (30) days of employment.
Salary Description
72,800 Yearly