Clinical Quality Specialist
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Job Description
Clinical Quality Specialist auditing Vynca’s Enhanced Care Management documentation and clinical quality. Translating findings into training, remediation, and audit readiness.
Responsibilities:
- Conduct internal chart audits of Lead Care Managers across contracted health plans
- Apply health plan audit criteria and Vynca internal quality standards
- Maintain audit cadence and select samples according to chart composition requirements
- Document findings with supporting evidence and analyze trends, risks, and opportunities
- Participate in inter-rater calibration exercises
- Support health plan and regulatory audit readiness, self-audit submissions, and corrective action plan responses
- Maintain master audit records and monthly and quarterly quality reporting
- Provide secondary clinical review of assessments, care management plans, and transitional care documentation
- Provide clinical oversight, coverage, escalation support, and clinical guidance for complex member scenarios
- Support interdisciplinary and multidisciplinary care team activity
- Review clinical content in training materials, assessments, and job aids
- Escalate clinical risk, member safety concerns, and quality-of-care issues
- Partner with ECM Operations to translate audit findings into workflow changes and remediation
- Collaborate on performance improvement plans and communicate results and at-risk staff to managers and directors
- Partner with Training and Development on curriculum updates, education huddles, and remediation training
- Support Compliance with audit readiness, regulatory monitoring, and QAPI activities
- Deliver onboarding, ongoing, audit-related, and post-remediation training as needed
- Develop criteria walkthroughs, documentation standards, findings reviews, knowledge checks, and competency tools
- Support preceptor and shadowing activities as a clinical subject matter resource
- Maintain audit-ready quality documentation
- Monitor CalAIM, DHCS, and health plan criteria changes
- Build and maintain plan-specific audit tools
- Support ad-hoc quality initiatives, policy development, and special projects
Requirements:
- Bachelor’s degree required
- Active, unrestricted California clinical licensure required (RN, LCSW, LMFT, LPCC, or equivalent), or ability to obtain California licensure within the first six months of employment
- 5+ years of experience in care management, case management, or direct clinical practice
- 1+ years of experience in quality auditing, chart review, utilization review, or QAPI activities
- Experience with documentation integrity, including reviewing clinical documentation for accuracy, completeness, timeliness, and defensibility under audit
- Willing and able to work Monday through Friday, 8:30am to 5pm Pacific Time
- Working knowledge of clinical documentation standards, care plan development, and transitional care requirements
- Strong analytical skills and ability to translate findings into actionable recommendations
- Exceptional written communication skills for documenting audit findings objectively and defensibly
- Ability to deliver difficult feedback constructively while maintaining professional credibility with clinical staff
- Proficiency with Google Suite, electronic health records, and virtual collaboration platforms such as Zoom and Microsoft Teams
- Ability to manage multiple priorities and competing deadlines
- Cultural competence and ability to interact effectively with diverse populations
- Experience with Medi-Cal populations, ECM, or CalAIM programs highly desirable
- Bilingual proficiency in English and Spanish preferred
- Familiarity with CalAIM, Enhanced Care Management, and community-based care models preferred
- Experience with health plan delegation audits and corrective action plans preferred
- CPHQ or CHC certification preferred
- Experience with training delivery, curriculum development, or adult learning principles preferred
- Experience with trauma-informed care or motivational interviewing preferred
- Advanced spreadsheet skills preferred
- Must complete background screening before employment
- Employees in patient, client, or customer-facing roles must be vaccinated against influenza, subject to accommodations
- Must satisfy 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 per IRS guidelines
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