Quality & Compliance Monitoring Coordinator

POSITION SUMMARY

Responsible for conducting routine monitoring activities to support documentation accuracy, billing compliance, and adherence to agency requirements. Reviews monitoring reports, follows up on identified issues, and assists with necessary corrections. Provides administrative and operational support for designated therapy programs, including referrals, authorizations, episode management, discharge processing, caseload monitoring, and other utilization management functions. Provides backup coverage for the Clinical Care Coordinator position, including client contact and triage of therapy referrals, as needed.

ESSENTIAL FUNCTIONS AND DUTIES

The essential functions include, but are not limited to the following:

- Runs monitoring reports in accordance with the agency’s annual audit plan to identify potential documentation and billing errors. Reviews identified issues, follows up with staff as needed, and completes or facilitates necessary corrections.

- Assists the Compliance Team with processing requests for corrections or changes to clinical documentation and billing records.

- Monitors caseloads for Youth, School-Based, and contract therapists to identify missing or untimely documentation and follows up with therapists and/or appropriate staff as needed.

- Processes referrals to the TAP program and completes required documentation and system entries.

- Opens therapy episodes and enters required authorizations for Youth and School-Based Therapy services.

- Processes therapy discharges for Youth, School-Based, and contract therapy services, including completion of required system updates.

- Receives requests for reauthorization. Reviews clinical documentation and prepares information for the Utilization Management (UM) Panel. Serves as chairperson of the UM Panel, presents cases for review, and completes reauthorization approval based on the Panel’s determination.

- Updates and maintains applicable therapy provider information and lists.

- Organizes therapy provider meetings as assigned.

- Sends letters and satisfaction surveys to clients who have not received therapy services within established timeframes.

- Sends reminders to providers regarding outstanding discharge documentation and follows up on delinquent discharge summaries.

- Provides backup coverage for the Clinical Care Coordinator position, including client contact and triage of therapy referrals, as needed.

- Provides support to the CQCO and Quality Improvement/Compliance functions as needed.

- Maintains knowledge of agency technology programs and systems required for the position and uses them effectively.

- Performs other duties and responsibilities as assigned by supervisor.

Minimum Qualifications (Knowledge, Skills, and Abilities)

Education/Certifications:

- Bachelor’s Degree in a behavioral health field

Experience Required:

- Prior experience in behavioral health preferred.

- Experience working with electronic health records (EHR/EMR) or other complex electronic information systems preferred.

- Experience with documentation review, data monitoring, auditing, billing, or quality/compliance activities preferred.

Required Knowledge:

- Knowledge of behavioral health services and clinical documentation practices.

- General understanding of healthcare billing, quality monitoring, and compliance processes.

- Knowledge of confidentiality requirements and the importance of accurate and complete client records.

- Knowledge of basic clinical triage and referral processes.

Skills/Abilities:

- Strong computer skills and demonstrated ability to learn and become proficient in the agency’s electronic health record (EHR/EMR) system and other technology platforms required for the position.

- Ability to efficiently navigate electronic client records, run and review reports, enter and update information accurately, and identify potential documentation, billing, or data discrepancies.

- Strong attention to detail and ability to identify inconsistencies, missing information, and potential errors.

- Ability to organize and manage recurring monitoring activities and follow identified issues through resolution.

- Strong analytical and problem-solving skills.

- Excellent written and verbal communication skills, including the ability to communicate identified issues clearly and professionally.

- Ability to communicate effectively with clients and assess information necessary to appropriately triage therapy referrals when providing backup coverage.

- Ability to manage multiple priorities and deadlines while maintaining accuracy.

- Ability to work collaboratively with staff at all levels.

- Ability to maintain a high level of client confidentiality.

- Proficiency with Microsoft 365 applications, particularly Outlook, Word, Excel, and Teams, with the ability to learn and effectively use additional technology tools required for the position.

Physical Demands and Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. The noise level in the work environment is usually low to moderate.