Quality Assurance Specialist

EmploymentType: Full-TimeCompensation: $27 – $33 per hourSchedule: Full-TimeWorkEnvironment: Hybrid / Minimum 40% OutreachLocation: Hybrid within hiring county

About Pacific Health GroupAt Pacific Health Group, we care deeply about the people and communities we serve. We meet individuals with kindness, respect, and understanding—listening first, honoring each person’s journey, and offering support without judgment.Through compassionate, person-centered healthcare, behavioral health services, and social supports, we walk alongside people as they work toward healing, stability, and a healthier, more hopeful life.

Our Core Values

• Speak with integrity—clear, respectful, and honest in every interaction.
• Embrace innovation, trying new ideas, learning fast, and improving care.
• Own our roles, staying accountable for outcomes and documenting accurately.
• Build genuine connections with members, families, and teammates through empathy and cultural sensitivity.
• Lead with trust by being consistent, transparent, and following through.
• Celebrate wins together, recognizing individual and team achievements.
• Collaborate with purpose, partnering across departments and with community providers to solve problems.
• Ask for support and offer support, because thriving together is how we serve our members best.

Role Overview & ImpactThe Quality Assurance Specialist ensures quality, compliance, workflow accuracy, and performance excellence across Enhanced Care Management (ECM), Community Supports (CS), Behavioral Health (BH), and Community Health Worker (CHW) operations. The QA Specialist serves as the internal auditor, workflow analyst, and process-improvement lead for all member-facing activities, including assessments, referrals, documentation, disenrollment workflows, re-engagement processes, outreach, verification, and communication functions.• This position strengthens operational integrity, ensures regulatory compliance, and builds a culture of accountability and continuous improvement within the Quality Assurance unit. This role directly impacts documentation accuracy, regulatory compliance, workflow efficiency, and member experience quality across the organization.• Outreach (Minimum 40%)• Conduct community-based outreach across multiple counties through in-person engagement and digital channels (phone, SMS, email, social media) to identify, engage, and enroll eligible members into ECM, CS, BH, and CHW programs. Build and maintain partnerships to expand access to services in high-need communities. A minimum of 40% of this role is dedicated to direct community outreach.

Key ResponsibilitiesQuality Assurance & Compliance Oversight

• Audit member records, assessments, and documentation to ensure compliance with ECM, CS, BH, CHW, CalAIM, and Medi-Cal standards.
• Monitor outreach, referral, and disenrollment workflows to ensure adherence to required timelines and regulatory guidelines.
• Ensure HIPAA compliance and data integrity across all member-facing processes.

Workflow Analysis & Process Improvement

• Evaluate ECM, CS, BH, and CHW workflows for accuracy, efficiency, and risk exposure.
• Identify trends, documentation gaps, and systemic errors.
• Develop corrective action plans and process improvements to enhance operational performance.

Performance Monitoring & Reporting

• Track QA metrics across documentation accuracy, outreach compliance, and verification standards.
• Generate reports outlining findings, trends, risk areas, and performance improvements.
• Collaborate with leadership to ensure ECM, CS, BH, and CHW QA metric thresholds are consistently achieved.

Cross-Functional Collaboration

• Partner with BH, CHW, CS, and ECM teams, Outreach, and leadership to reinforce quality standards.
• Provide feedback, coaching, and training based on audit findings.
• Support implementation of new workflows and regulatory updates.

Success Measures

• 95%+ documentation accuracy across all workflows.
• 100% compliance with required outreach standards (minimum 40% field-based).
• Accurate verification across all member profiles.
• Complete and timely disenrollment cycle documentation.
• Consistent achievement of ECM, CS, BH, and CHW QA metric thresholds.

Skills That Set You ApartRequired Qualifications

• Bachelor’s degree in Healthcare Administration, Public Health, Social Work, or related field.
• 2+ years of experience in quality assurance, care coordination, compliance, or healthcare program auditing.
• Familiarity with ECM, CS, BH, CHW, CalAIM, Medi-Cal, HIPAA, and care coordination workflows.
• Strong analytical and problem-solving skills.
• Excellent documentation, communication, and interpersonal skills.
• Proficiency in CRM/EMR systems and Excel.
• Driver's License and Reliable transportation required for 40% outreach

Benefits

• Time Off & Leave: 160 hours of Paid Time Off (PTO) and Paid Sick Time; 11 paid holidays per year (including birthday); 4 paid volunteer hours per month; Bereavement leave (including fur babies).
• Health & Wellness: 90% employer-paid employee-only medical benefits; Flexible Spending Account (FSA); Short-term & long-term disability, AD&D, and Employee Assistance Program (EAP).
• Financial & Professional: 401(k) with company match; Professional development and growth opportunities.
• Culture & Perks: Employee discount programs and quarterly in-person events.