Quality Assurance Specialist - Community Supports

• Employment Type:
  
  Full-Time

• Compensation: $27 – $33 per hour

• Schedule:
  
  Full-Time

• Work Environment:
  Hybrid / Minimum 40% Outreach & Field Auditing

• Location:
  
  Hybrid within hiring county

At Pacific Health Group, we care deeply about the people and communities we serve. We meet individuals with kindness, respect, and understanding—listening first, honoring each person’s journey, and offering support without judgment.

Through compassionate, person-centered healthcare, behavioral health services, and social supports, we walk alongside people as they work toward healing, stability, and a healthier, more hopeful life.

• Speak with integrity—clear, respectful, and honest in every interaction.
• Embrace innovation, trying new ideas, learning fast, and improving care.
• Own our roles, staying accountable for outcomes and documenting accurately.
• Build genuine connections with members, families, and teammates through empathy and cultural sensitivity.
• Lead with trust by being consistent, transparent, and following through.
• Celebrate wins together, recognizing individual and team achievements.
• Collaborate with purpose, partnering across departments and with community providers to solve problems.
• Ask for support and offer support, because thriving together is how we serve our members best.

The Quality Assurance Specialist – Community Supports (CS) ensures documentation accuracy, compliance, and workflow integrity specifically across all CalAIM Community Supports service lines (such as Housing Transition/Tenancy, Medically Tailored Meals, Recuperative Care, and Environmental Adaptations). Serving as the subject matter expert on CS guidelines, this role audits member authorizations, service delivery documentation, billing/invoice integrity, and provider network compliance.

This position strengthens operational integrity, ensures regulatory compliance with Managed Care Plans (MCPs) and DHCS guidelines, and drives continuous process improvement across CS workflows. The CS QA Specialist directly impacts claim approval rates, regulatory compliance, sub-recipient/CBO oversight, and overall quality of social care delivery.

Conduct community- and site-based outreach and auditing across target counties. This includes field-based audits of contracted Community Supports vendors/CBOs, evaluating physical compliance (e.g., housing or environmental modification standards), verifying member service delivery directly in the field, and conducting outreach to community partners to align quality standards. A minimum of 40% of this role is dedicated to direct community outreach.

• Conduct routine and targeted audits of Community Supports member files, authorization requests, and individual service plans to ensure alignment with CalAIM, DHCS, and Managed Care Plan standards.
• Audit documentation for specific CS service lines (e.g., verifying proof of housing transition steps, meal delivery tracking, recuperative care length-of-stay logs, and home adaptation receipts).
• Verify that member eligibility assessments, authorizations, and disenrollment workflows adhere to required timelines and regulatory mandates.
• Ensure strict adherence to HIPAA guidelines, member consent protocols, and privacy standards across all CS platforms and external provider exchanges.

• Evaluate CS intake, referral, authorization, and service delivery workflows for gaps, inefficiencies, and compliance risks.
• Track error trends, documentation deficiencies, and billing/invoice discrepancies between internal care teams and external CS vendors.
• Formulate Corrective Action Plans (CAPs) and lead…