Clinical Quality Assurance Specialist, RN

About the role

We are seeking a Quality Assurance Specialist, RN, to build and run our clinical Quality Assurance program. This role involves hands-on operations, focusing on ensuring clinical documentation meets billing standards, billing compliance, and supporting health plan audits.

Responsibilities

• Review patient charts on a regular schedule for both new hires and current staff.
• Pull random samples and maintain monthly QA records and audit documentation.
• Ensure documentation and billing compliance, making sure every patient encounter meets billing standards with clear clinical reasoning.
• Work with the Billing team to resolve unclear cases.
• Report larger patterns and gaps to leadership, along with suggested fixes.
• Help prepare the team for new or changing standards.
• Partner with Operations on workflow and automation fixes, with Billing on documentation and revenue issues, and with the Training and Enablement Specialist to close skill gaps through targeted training.
• Add a clinical quality scoring system with clear standards for coaching and escalation, adding these scores to performance reviews.
• Own and grow the QA program overall, including tracking, scoring rules, adverse event reporting, grievance handling, and support for health plan audits.
• Keep a clear line between clinical QA and billing QA, and manage the handoff between the two.

Requirements

• An active, unrestricted RN, NP, LPN, or LCSW license (a multi-state or compact license is preferred).
• At least 3 years of clinical experience, plus experience in operations or quality — ideally at a healthcare organization or a fast-growing healthcare startup.
• Hands-on experience reviewing charts for billing compliance. You know what a clean, well-written note looks like.
• A strong understanding of documentation rules for Medicare, Medicaid, and value-based care. Knowledge of community health billing (CHI/PIN, CHW services) is a plus.
• An operations mindset. You don't just spot problems — you build systems that prevent them. You think in terms of schedules, scoring systems, trackers, and automation.
• A tech-forward attitude. You look for ways to use technology, automation, and AI to grow a quality program, and you pick up new tools quickly.
• Openness to feedback. You give direct, honest feedback and welcome it in return. You see feedback as a tool for growth, not a threat.
• A proactive, persistent attitude, with a strong drive to take action and solve problems.
• Comfort working in a fast-changing, sometimes uncertain environment.
• Strong project management and prioritization skills, along with close attention to detail.
• Skill in data analysis. You can pull, sort, and understand QA data on your own.
• Strong collaboration skills across teams. You do well working between Operations, Billing, Training, and frontline staff.
• Comfort using technology, including EHR systems, Slack, Google Suite, and QA or audit tools.