Quality Assurance Specialist

About Pacific Health Group

Pacific Health Group is dedicated to serving individuals and communities with kindness, respect, and understanding. We prioritize listening, honoring personal journeys, and offering non-judgmental support. Through person-centered healthcare, behavioral health services, and social support, we assist individuals in their pursuit of healing, stability, and a healthier future. Our core values include integrity, innovation, accountability, genuine connection, trust, celebrating wins, collaboration, and mutual support.

Role Overview & Impact

The Quality Assurance Specialist is crucial for maintaining quality, compliance, and operational efficiency across Enhanced Care Management (ECM), Community Supports (CS), Behavioral Health (BH), and Community Health Worker (CHW) programs. This role involves internal auditing, workflow analysis, and driving process improvements for all member-facing activities, including assessments, referrals, documentation, and outreach. The Specialist will enhance operational integrity, ensure regulatory adherence, and foster a culture of continuous improvement within the Quality Assurance team, directly impacting documentation accuracy, compliance, workflow efficiency, and member experience.

Outreach (Minimum 40%)

A significant portion of this role, at least 40%, involves community-based outreach. This includes in-person engagement and digital communication (phone, SMS, email, social media) to identify, engage, and enroll eligible members into ECM, CS, BH, and CHW programs. Building community partnerships to expand service access in underserved areas is a key objective.

Key Responsibilities

• Quality Assurance & Compliance Oversight: Audit member records, assessments, and documentation to ensure adherence to ECM, CS, BH, CHW, CalAIM, and Medi-Cal standards. Monitor outreach, referral, and disenrollment workflows for compliance with timelines and regulations. Ensure HIPAA compliance and data integrity.
• Workflow Analysis & Process Improvement: Evaluate ECM, CS, BH, and CHW workflows for accuracy, efficiency, and potential risks. Identify trends, documentation deficiencies, and systemic errors. Develop and implement corrective action plans and process enhancements.
• Performance Monitoring & Reporting: Track key performance indicators (KPIs) for documentation accuracy, outreach compliance, and verification standards. Generate reports detailing findings, trends, risks, and improvement initiatives. Collaborate with leadership to meet QA metric thresholds.
• Cross-Functional Collaboration: Work closely with BH, CHW, CS, and ECM teams, Outreach departments, and leadership to reinforce quality standards. Provide constructive feedback, coaching, and training based on audit outcomes. Support the integration of new workflows and regulatory changes.

Success Measures

• Achieve over 95% documentation accuracy across all operational workflows.
• Maintain 100% compliance with required outreach standards, with a minimum of 40% field-based activity.
• Ensure accurate verification for all member profiles.
• Complete and timely documentation for the entire disenrollment cycle.
• Consistently meet established QA metric thresholds for ECM, CS, BH, and CHW programs.

Additional Information

Employment Type: Full-Time
Compensation: $27 - $33 per hour
Schedule: Full-Time
Work Environment: Hybrid with a minimum of 40% outreach.
Location: Hybrid within the hiring county.
Required: Driver's License and reliable transportation for 40% outreach duties.