Clinical Quality Specialist

This is a fully remote position, open to applicants in Arizona, +10 more states.

📋 Description

• Perform internal chart audits of Lead Care Managers within contracted health plans.

• Implement health plan audit criteria alongside Vynca's internal quality standards.

• Uphold the audit schedule and choose samples based on chart composition requirements.

• Record findings with supporting evidence and assess trends, risks, and opportunities.

• Engage in inter-rater calibration exercises.

• Assist in health plan and regulatory audit preparedness, self-audit submissions, and responses to corrective action plans.

• Maintain master audit records along with monthly and quarterly quality reports.

• Conduct secondary clinical reviews of assessments, care management plans, and transitional care documentation.

• Provide clinical oversight, coverage, escalation support, and clinical guidance for complex member situations.

• Facilitate interdisciplinary and multidisciplinary care team activities.

• Evaluate clinical content in training materials, assessments, and job aids.

• Raise concerns regarding clinical risks, member safety, and quality-of-care issues.

• Collaborate with ECM Operations to convert audit findings into workflow modifications and remediation efforts.

• Work together on performance improvement plans, communicating results and identifying at-risk staff to managers and directors.

• Team up with Training and Development for curriculum updates, education huddles, and remediation training.

• Assist with Compliance regarding audit readiness, regulatory monitoring, and QAPI activities.

• Provide onboarding, continuous, audit-related, and post-remediation training as required.

• Create criteria walkthroughs, documentation standards, findings reviews, knowledge checks, and competency tools.

• Support preceptor and shadowing initiatives as a clinical subject matter resource.

• Ensure audit-ready quality documentation is maintained.

• Monitor changes to CalAIM, DHCS, and health plan criteria.

• Develop and sustain plan-specific audit tools.

• Assist with ad-hoc quality initiatives, policy formulation, and special projects.

⛳️ Requirements

• Bachelor's degree is required.

• Active, unrestricted California clinical licensure is required (RN, LCSW, LMFT, LPCC, or equivalent), or the ability to obtain California licensure within the first six months of employment.

• A minimum of 5 years of experience in care management, case management, or direct clinical practice.

• At least 1 year of experience in quality auditing, chart review, utilization review, or QAPI activities.

• Proven experience with documentation integrity, including reviewing clinical documentation for accuracy, completeness, timeliness, and defensibility during audits.

• Must be willing and able to work Monday through Friday, from 8:30 am to 5 pm Pacific Time.

• Working knowledge of clinical documentation standards, care plan creation, and transitional care requirements.

• Strong analytical abilities and the capacity to translate findings into actionable recommendations.

• Excellent written communication skills for objectively and defensibly documenting audit findings.

• Capability to provide constructive feedback while preserving professional credibility with clinical staff.

• Proficient in Google Suite, electronic health records, and virtual collaboration platforms like Zoom and Microsoft Teams.

• Ability to juggle multiple priorities and meet competing deadlines.

• Cultural competence and skill in effectively interacting with diverse populations.

• Experience with Medi-Cal populations, ECM, or CalAIM programs is highly desirable.

• Bilingual proficiency in English and Spanish is preferred.

• Familiarity with CalAIM, Enhanced Care Management, and community-based care models is preferred.

• Experience with health plan delegation audits and corrective action plans is preferred.

• CPHQ or CHC certification is preferred.

• Experience in training delivery, curriculum development, or adult learning principles is preferred.

• Experience with trauma-informed care or motivational interviewing is preferred.

• Advanced spreadsheet skills are preferred.

• Must complete background screening prior to employment.

• Employees in patient, client, or customer-facing roles must be vaccinated against influenza, subject to accommodations.

• Must comply with U.S. employment eligibility verification through E-Verify.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Income protection benefits.

• Flexible PTO.

• Company holidays.

• 401k.

• Wellness benefits.

• Mileage reimbursement for field roles as per IRS guidelines.