QA/QC Clinical Documentation Specialist

About the role

The QA/QC Clinical Documentation Specialist ensures the accuracy, completeness, and regulatory compliance of clinical records within the behavioral health organization. This role reviews clinical documentation for adherence to state licensing requirements, payer standards, accreditation bodies and internal policies, supporting audit readiness and continuous quality improvement.

Responsibilities

• Conduct routine audits of clinical documentation (assessments, treatment plans, progress notes, discharge summaries) for accuracy, timeliness, and compliance with state, federal, and payer regulations
• Verify documentation supports medical necessity and aligns with treatment plans and level-of-care Requirements
• Identify documentation deficiencies and provide feedback to Qualified Mental Health Professional (QMHP) staff and supervisors
• Monitor compliance with confidentiality standards, such as HIPAA
• Maintain audit logs, tracking tools, and quality metrics/reports for leadership review
• Support preparation for accreditation surveys (CARF, Joint Commission) and state licensing audits by organizing and validating required documentation
• Collaborate with clinical, billing, and compliance teams to resolve documentation discrepancies affecting claims or audits
• Develop and update documentation templates, checklists, and job aids to standardize clinical record-keeping
• Provide training to Qualified Mental Health Professionals (QMHPs) on documentation standards, timelines, and best practices
• Stay current on changes to state behavioral health regulations and payer documentation requirements

Qualifications

• Bachelor's degree in behavioral health, social work, healthcare administration, or related field (clinical licensure a plus but not always required)
• 2+ years of experience in behavioral health, clinical documentation review, quality assurance, or compliance
• Working knowledge of HIPAA
• Familiarity with EHR systems used in behavioral health (e.g., Lauris)
• Strong attention to detail and ability to interpret clinical language and treatment planning
• Excellent written and verbal communication skills for delivering feedback to clinical staff
• Ability to manage multiple audits and deadlines simultaneously

Benefits

• Competitive benefits
• Training
• Trauma-informed, culturally responsive care
• A team that truly supports each other