Quality Assurance Specialist

SUMMARY OF POSITION

Reporting to the Sr. Director of Clinical Services and Program Innovation, the Quality Assurance Specialist is responsible for supporting the integrity, accuracy, compliance, and timely billing of Drug Medi-Cal (DMC) substance use disorder services provided by NCADD-SFV.

This position serves as a key quality control function between clinical service delivery, documentation, billing, and program operations. The Quality Assurance Specialist reviews clinical documentation and service data to verify that services submitted for reimbursement are supported by the patient record, appropriately documented, medically necessary, delivered by qualified staff, and compliant with applicable Los Angeles County Department of Public Health Substance Abuse Prevention and Control (SAPC), California Department of Health Care Services (DHCS), Medi-Cal, CalAIM, and organizational requirements.

The position requires hands‑on experience with Los Angeles County DMC billing and documentation workflows, including Sage-PCNX or other applicable SAPC systems. The Quality Assurance Specialist conducts pre‑billing reviews, identifies documentation and billing discrepancies, communicates corrections to clinical and administrative staff, tracks resolution of identified issues, and supports timely and accurate claims submission.

The Quality Assurance Specialist also conducts ongoing chart reviews, internal audits, utilization and documentation monitoring, and quality improvement activities. The position works collaboratively with clinical leadership, counselors, LPHA staff, administrative staff, Finance, and executive leadership to strengthen compliance and reduce organizational exposure to billing errors, disallowances, recoupments, fraud, waste, and abuse.

• Review DMC services prior to billing to verify that services are supported by complete and compliant documentation.
• Validate service dates, service types, duration, units, rendering providers, locations, and other billing information against the clinical record.
• Review services entered into Sage-PCNX and applicable electronic health record systems for accuracy and consistency.
• Identify duplicate services, overlapping services, unsupported units, missing documentation, incorrect service codes, and other billing discrepancies.
• Verify that services submitted for reimbursement were actually rendered and appropriately documented.
• Review documentation to ensure billed services are consistent with the patient's treatment needs and applicable medical necessity requirements.
• Verify that rendering practitioners possess the appropriate credentials, registration, certification, licensure, or scope of practice for services provided.
• Coordinate corrections with clinical and administrative staff prior to claim submission.
• Track outstanding billing corrections and follow through until discrepancies are appropriately resolved.
• Assist with denied, rejected, or otherwise problematic claims and identify recurring billing issues requiring corrective action.

• Conduct routine reviews of patient records for completeness, accuracy, timeliness, and regulatory compliance.
• Review assessments, problem lists, treatment and care planning documentation, progress notes, group documentation, discharge documentation, care coordination records, and other required clinical documentation.
• Evaluate whether documentation adequately supports the service provided and billed.
• Review documentation for consistency between the patient's identified needs, services provided, interventions, response to treatment, and ongoing plan of care.
• Identify missing signatures, incomplete documentation, incorrect dates, inconsistent information, and other documentation deficiencies.
• Communicate deficiencies clearly to responsible staff and establish timelines for correction when appropriate.
• Monitor correction of identified deficiencies and elevate unresolved or recurring concerns to clinical leadership.
• Support implementation of standardized documentation practices across NCADD‑SFV clinical programs.