Billing Compliance/Documentation QA Specialist

POSITION SUMMARY

Makes sure every billed service is backed by documentation that meets Medi-Cal, DHCS, and County standards, so claims hold up when audited or reconciled. Also owns the separate tracking and reporting of non-Medi-Cal services (ISL) under Exhibit D.

Essential Duties and Responsibilities

• Update and verify that all forms used in intake packets and all informing materials (for example, the Medi-Cal beneficiary handbook, the Notice of Privacy Practices, and grievance and appeal notices) are the current County and DHCS versions. Remove outdated versions from use.
• Audit a sample of progress notes, assessments, and care plans each month against SMHS documentation standards, CalAIM requirements, and County documentation manuals.
• Confirm required items are done and documented on time: the CANS, the PSC-35 (parent-completed), ASAM screening for clients with substance use needs, the HFW Decision Support Criteria steps, and signatures and credentials.
• Match documented services to claims, checking codes, units, and time, before and after billing. Flag any claims that need to be voided or corrected.
• Identify duplicate client records (MRNs) and send MRN duplication requests to HCA through IRIS. Track each request until it's resolved, so services, claims, and ISL data post to the correct client record.
• Give HFW and ICM staff and supervisors written feedback and correction requests, and track them until they're resolved.
• Train new hires and give refreshers on documentation and billing standards, in coordination with HR Training.
• Collect and submit Exhibit D ISL data (non-Medi-Cal services and Flexible Fund spending at the individual-client level), using only the ISL codes the County issues. Fix data errors within County deadlines.
• Help prepare the monthly programmatic report, including the client-to-staff ratios as of month-end.
• Track documentation and billing KPIs for the QA/QI program, and suggest fixes when standards are not being met.
• Help with County, State, and internal compliance audits, including corrective action plans.
• Report suspected billing irregularities to the Compliance Officer.