Quality Improvement & Compliance Specialist

Counseling + Recovery Services; Tulsa (OK); On-site; USD 45,000 - 72,000; Full time

Job summary

Counseling + Recovery Services in Oklahoma seeks a Quality Assurance & Quality Improvement (QAQI) specialist to advance clinical documentation quality and compliance across behavioral health services. You will lead audits, support performance improvement, and coach clinicians on evidence-based practices, while ensuring alignment with CARF, ODMHSAS, OHCA, and DHS standards.

This role requires meticulous attention to detail and collaborative problem-solving.

Qualifications

• Master’s degree in counseling, social work, or related field.
• Must be licensed or licensed eligible (LPC/LMFT/LCSW).
• Experience with CARF, ODMHSAS, OHCA, and DHS standards preferred.
• Minimum one year in clinical quality improvement, chart auditing, or related behavioral health services.
• Experience with trauma-informed care preferred.

Responsibilities

• Assist in implementing and monitoring QAQI initiatives to meet standards.
• Conduct qualitative reviews of behavioral health records for compliance with CARF/OHCA/ODMHSAS.
• Serve as clinical lead for quarterly peer reviews and translate findings into coaching recommendations.
• Review documentation to verify medical necessity for services.
• Maintain records of coaching and corrective actions for QAQI.
• Support accreditation readiness and licensure preparation activities.
• Provide staff coaching on clinical documentation and related workflows.
• Identify training needs from audits to inform content.
• Other duties as assigned.

Skills

QAQI processes

Clinical documentation

Data tracking

Coaching & facilitation

Clinical record reviews

Independent work

Team collaboration

Sanctuary Model

Code of Ethics

Training delivery

Education

Master’s degree in counseling/social work

Licensed or eligible (LPC/LMFT/LCSW)

Tools

Excel

Electronic Health Records

Job description

Brief Description

SPECIAL KNOWLEDGE, SKILLS AND ABILITIES:

• Strong understanding of Quality Assurance and Quality Improvement processes in healthcare, clinical documentation standards, and evidence-based practices.
• Ability to conduct clinical record reviews and support performance improvement initiatives.
• Excellent communication, coaching, and facilitation skills, with experience delivering clinical documentation and compliance training.
• Proficiency in data tracking and report tools (e.g., Excel, EHR systems).
• Strong attention to detail and ability to manage multiple tasks simultaneously.
• Ability to work independently with moderate latitude for the use of initiative and independent judgment in fulfilling job responsibilities, and to collaborate effectively within a team environment.
• Ability to adapt to working in a fast-paced environment.
• Practices and promotes the Sanctuary Model’s Seven Commitments: nonviolence, emotional intelligence, social learning, open communication, social responsibility, democracy, and growth and change.
• Uphold CRS Code of Ethics by conducting professional activities with honesty, integrity, respect, fairness, and good faith in a manner that reflects positively upon the organization.

Brief Description

SPECIAL KNOWLEDGE, SKILLS AND ABILITIES:

• Strong understanding of Quality Assurance and Quality Improvement processes in healthcare, clinical documentation standards, and evidence-based practices.
• Ability to conduct clinical record reviews and support performance improvement initiatives.
• Excellent communication, coaching, and facilitation skills, with experience delivering clinical documentation and compliance training.
• Proficiency in data tracking and report tools (e.g., Excel, EHR systems).
• Strong attention to detail and ability to manage multiple tasks simultaneously.
• Ability to work independently with moderate latitude for the use of initiative and independent judgment in fulfilling job responsibilities, and to collaborate effectively within a team environment.
• Ability to adapt to working in a fast-paced environment.
• Practices and promotes the Sanctuary Model’s Seven Commitments: nonviolence, emotional intelligence, social learning, open communication, social responsibility, democracy, and growth and change.
• Uphold CRS Code of Ethics by conducting professional activities with honesty, integrity, respect, fairness, and good faith in a manner that reflects positively upon the organization.

Example Of Position Responsibilities

Quality Assurance & Quality Improvement (QAQI)

• Assist in the implementation and monitoring of QAQI initiatives to ensure services meet best-practice standards and regulatory requirements.
• Conduct qualitative reviews of behavioral health clinical records, including annual documentation audits for all behavioral health clinical staff, as assigned by the QAQI Director, to evaluate the clinical appropriateness, individualization, and quality of documentation in accordance with ODMHSAS, OHCA, and CARF standards.
• Serve as clinical lead for the agency’s quarterly peer reviews in accordance with CARF standards, including maintaining the review tools, training clinician reviewers, and translating findings into coaching and training recommendations.
• Conduct service-to-documentation reviews of billed behavioral health services to evaluate whether clinical documentation supports medical necessity for the services provided (e.g., behavioral health diagnosis, assessed need, and service plan justify the type and amount of service), in accordance with OHCA, ODMHSAS, and CCBHC requirements.
• Conduct follow-up assessments to evaluate whether corrective action plans and documentation training have effectively improved the clinical quality of documentation.
• Maintain records of coaching and corrective actions and report them to the QAQI Director; submit qualitative review results to the QA Business Intelligence Specialist for aggregation and trend reporting.
• Assist with critical incident review and compliance with regulatory reporting requirements and agency procedure adherence.
• Serve as a resource to staff regarding audit processes, findings, and expectations.
• Support accreditation survey readiness and state licensure/renewal preparation activities, including evidence collection, documentation review, and staff preparation, as directed by the QAQI Director.
• Staff Coaching & Documentation Training
• Provide individualized coaching to clinicians and support staff on clinical documentation, related workflows, and documentation of evidence-based practices, based on audit and review findings.
• Serve as the clinical documentation and compliance content expert for training developed and scheduled by the Training Specialist, including co-facilitating sessions on documentation and compliance topics.
• Assist with clinical documentation training for newly hired clinical staff as part of onboarding coordinated by the Training Specialist, in alignment with CCBHC protocols.
• Identify documentation-related training needs from audit and review findings and share them with the QAQI Director and Training Specialist to inform training content.
• Other duties as assigned

Hipaa

This position is permitted to locate information necessary to follow through with client care or provide authorization for release of information outside agency. Information should be requested from medical records staff initially, or with authorization from administration, retrieving necessary information without supervision.

Safety-sensitive

Counseling & Recovery Services of Oklahoma has designated this position as “safety- sensitive.” Employees who work in positions classified as “safety-sensitive” can be disciplined if they test positive for marijuana or its metabolites. Possession or use of medical marijuana while at work or during hours of employment regardless of whether the employee has a valid Oklahoma medical marijuana license, is still strictly prohibited.

Required Training

SPARS

New Hire Orientation (Initial) Harassment Annual Workplace Violence Annual Safety & Fire Training Annual

Sanctuary Initial 2-Day Training and Two Annual Booster training

Requirements

All other required training as assigned.

Minimum Qualifications

Possession of a master’s degree in counseling, social work, or other mental health-related field from an accredited graduate school. Must be licensed or licensed eligible. (LPC, LMFT, LCSW). Experience with CCBHC standards and trauma-informed care preferred.

Experience

Minimum of one year’s experience, as determined by the agency, in clinical quality improvement, chart auditing, or related behavioral health services. Experience with CARF, ODMHSAS, OHCA, and DHS standards preferred.

General Expectation

This position will play a key role in advancing the organization’s commitment to excellence in service delivery through robust Quality Assurance and Quality Improvement (QAQI) practices and documentation-focused staff coaching. This role requires a proactive and detail-oriented professional who can ensure compliance with regulatory standards (ODMHSAS, DHS, OHCA and CARF), promote best practices, and foster a culture of continuous learning and improvement.

Summary

All other required training as assigned.