Quality Assurance Specialist

Position Summary: The Quality Assurance Specialist is responsible for developing and maintaining high-quality, person-centered Individualized Service Plans (ISPs) that meet DBHDS, Medicaid, and HCBS requirements. This position manages service authorizations, monitors service delivery for compliance, and may prepare quarterly and annual service reviews. The Coordinator works closely with Program Managers, Direct Support Professionals, and external stakeholders to ensure all documentation and service delivery align with regulatory requirements and organizational standards.

Essential Duties & Responsibilities

1. Individualized Plan Development & Maintenance

• Participate in all individual support plan meetings and document minutes in PHS. Coordinate all admissions and discharge processes for all individuals in conjunction with the program Director.

• Set up new individual record in PHS and activate all charts, per support plan needs.

• Scan, upload, and update all individual-related information in Practical Health Systems.

• Draft, update, and maintain Individualized Service Plans (ISPs) in accordance with DBHDS, Medicaid, and HCBS standards.

• Collaborate with individuals, guardians, case managers, and interdisciplinary teams to ensure goals and supports are person-centered and measurable.

• Ensure all ISPs are completed, signed, and implemented within required timelines.

• Update ISPs promptly in response to changes in needs, services, or circumstances.

• Ensuring all quarterlies are completed on time and uploaded to WAMS.

2. Service Authorization Management

• Request, track, and manage service authorizations from Managed Care Organizations (MCOs) or Community Services Boards (CSBs).

• Maintain accurate records of authorization periods, units, and service codes.

• Monitor service utilization to prevent over- or under-billing.

• Coordinate with billing and program teams to ensure accurate documentation supports claims.

• Individual Eligibility Checks;

• Ensuring addresses for individuals are updated in WAMS and DMAS with the correct FIPS code (DMAS 225).

3. Compliance Monitoring

• Conduct regular internal reviews of service delivery documentation to ensure regulatory compliance.

• Identify discrepancies or potential deficiencies and coordinate corrective actions.

• Maintain knowledge of current DBHDS, Medicaid, and HCBS regulations and update policies/procedures accordingly.

• Participate in audits, site visits, and licensing inspections, providing requested documentation and reports.

• Review WAMS/Other External Systems daily, address concerns and provide reports.

• Perform regular quality assurance and risk management duties/audits as assigned

4. Service Review & Reporting

• Prepare quarterly and/or annual progress summaries for each individual served, reflecting goal progress, service effectiveness, and recommendations.

• Ensure all reports are data-driven, accurate, and submitted within required deadlines.

• Use service data to identify trends, successes, and areas for improvement.

5. Collaboration & Training

• Work with program staff to ensure ISP goals and objectives are understood and implemented.

• Provide training to staff on documentation requirements, goal measurement, and compliance standards.

• Serve as a resource for staff regarding regulatory requirements and person-centered planning best practices.

• Other duties as assigned by the Program Director, Director of Operations, or Executive Director.