layiq

/la·yiq/adjective

worthy; deserving; fitting; suitable.

A role, opportunity, or path that merits attention, time, and pursuit.

LAYIQ - Quality Assurance Specialist - Community Supports at Pacific Health Group

CS Compliance & Record Auditing
Conduct routine and targeted audits of Community Supports member files, authorization requests, and individual service plans to ensure alignment with CalAIM, DHCS, and Managed Care Plan standards.
Audit documentation for specific CS service lines (e.g., verifying proof of housing transition steps, meal delivery tracking, recuperative care length-of-stay logs, and home adaptation receipts).
Verify that member eligibility assessments, authorizations, and disenrollment workflows adhere to required timelines and regulatory mandates.
Ensure strict adherence to HIPAA guidelines, member consent protocols, and privacy standards across all CS platforms and external provider exchanges.
Workflow Analysis & CS Process Improvement
Evaluate CS intake, referral, authorization, and service delivery workflows for gaps, inefficiencies, and compliance risks.
Track error trends, documentation deficiencies, and billing/invoice discrepancies between internal care teams and external CS vendors.
Formulate Corrective Action Plans (CAPs) and lead process-improvement initiatives to resolve systemic documentation issues.
CBO & Provider Network Quality Oversight
Monitor contracted Community Supports service providers and CBO partners to verify that delivered services match billed claims and documented care plans.
Collaborate with internal teams to ensure provider invoice reconciliations meet quality and compliance thresholds before submission to Managed Care Plans.
Performance Monitoring, Reporting & Collaboration
Track and maintain core CS quality metrics, including assessment timeliness, authorization pass rates, documentation accuracy, and audit scorecards.
Generate regular compliance reports for program leadership outlining error trends, risk areas, and audit findings.
Partner with CS Coordinators, ECM leads, and operational managers to provide feedback, direct coaching, and training based on audit findings.
Success Measures
95%+ documentation accuracy across all audited Community Supports member files and authorizations.
100% adherence to required auditing and community outreach activities (minimum 40%).
Zero major compliance findings during Managed Care Plan (MCP) or State audits of CS records.
Timely execution and resolution of Corrective Action Plans (CAPs) for internal teams and external providers.
High reconciliation accuracy between documented CS service delivery and submitted billing claims.
Skills That Set You Apart
Required Qualifications
Bachelor’s degree in Healthcare Administration, Public Health, Social Work, Quality Management, or a related field.
2+ years of experience in quality assurance, compliance auditing, care coordination quality review, or healthcare program oversight.
Direct familiarity with CalAIM Community Supports (CS) service definitions, ECM, Medi-Cal guidelines, HIPAA, and Managed Care Plan audit requirements.
Proven ability to analyze complex healthcare/social service workflows and audit EMR/CRM documentation for compliance gaps.
Strong written, analytical, and interpersonal skills, with experience delivering constructive feedback and training to operational teams.
Proficiency with EMR/EHR platforms, CRM systems, and Microsoft Excel (data tracking, audit log management).
Valid Driver's License, active auto insurance, and reliable transportation required for 40% field visits and site audits.

Quality Assurance Specialist - Community Supports

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