Role Description
The Clinical Documentation Reviewer & QA Consultant will conduct comprehensive reviews of clinical documentation, assessments, treatment plans, and service notes to ensure compliance with DBHDD, CORE Behavioral Health standards, Medicaid requirements, and agency policies. This position will also provide training, coaching, and constructive feedback to clinical staff to improve documentation quality and reduce compliance risks.
This role is ideal for a licensed clinician or healthcare professional with experience in behavioral health documentation, quality assurance, auditing, utilization review, or healthcare compliance.
Essential Duties and Responsibilities
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Review clinical service notes for accuracy, completeness, and compliance.
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Review assessments, treatment plans, safety plans, and related clinical documentation.
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Identify documentation deficiencies, trends, compliance concerns, and potential audit risks.
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Provide written and verbal feedback to clinical staff regarding documentation improvements.
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Train and educate staff on DBHDD documentation requirements and best practices.
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Assist with quality assurance initiatives and continuous quality improvement activities.
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Participate in quality assurance meetings and interdisciplinary discussions as needed.
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Support preparation for audits, surveys, and regulatory reviews.
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Assist leadership in identifying corrective actions and quality improvement opportunities.
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Review agency documentation processes and recommend improvements.
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Consult regarding policy and procedure development related to documentation and compliance.
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Maintain strict confidentiality and HIPAA compliance at all times.
Qualifications
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Minimum of three (3) years of clinical experience in behavioral health, healthcare, nursing, social work, counseling, case management, utilization review, quality assurance, compliance, or related field.
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Strong understanding of clinical documentation standards and medical record review.
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Experience reviewing clinical notes, assessments, treatment plans, and service documentation.
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Excellent written communication and documentation skills.
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Strong organizational and analytical skills.
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Ability to provide constructive feedback and training to clinical staff.
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Proficiency with Electronic Medical Records (EMR) systems.
Preferred Qualifications
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Active LPC, LCSW, LMFT, RN, PsyD, PhD, or other related clinical licensure.
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Experience working within DBHDD CORE Services.
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Previous experience in Quality Assurance (QA), Utilization Review (UR), Compliance, Auditing, Risk Adjustment, or Managed Care.
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Experience conducting chart audits and identifying documentation deficiencies.
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Previous experience with Medicaid, Medicare, CareSource, Amerigroup, Peach State, or other managed care documentation requirements.
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Experience training, coaching, or supervising clinical staff.
Compensation & Benefits
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Competitive starting rate of $40.00 per hour.
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Opportunities for compensation increases based on performance, demonstrated expertise, and contribution to agency quality improvement efforts.
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Flexible scheduling.
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Remote work opportunities available.
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Opportunity to help shape quality assurance and compliance processes within a growing behavioral health agency.
How to Apply
Qualified candidates should submit a resume, current licensure (if applicable), and a brief summary of their experience in clinical documentation review, quality assurance, compliance, auditing, or behavioral health services.
