Documentation Quality & Compliance

Department: Compliance / Quality Assurance
Location: Hybrid Woodland Hills CA
Status: Full-Time, Non-Exempt

Profound Treatment is built on the core values of compassion, integrity, and excellence. We are dedicated to providing a safe and nurturing environment where individuals can embark on their recovery journey. Our approach focuses on treating the whole person—mind, body, and spirit—through evidence-based therapies and personalized care.

Working at Profound Treatment means joining a team that is passionate about making a positive impact on people's lives. We prioritize continuous learning and professional growth, ensuring our staff are equipped with the latest knowledge and skills. Our supportive and inclusive culture fosters a sense of belonging and fulfillment, making it a truly rewarding place to work.

Be part of a community that values healing, growth, and making a profound difference in the lives of those we serve. Join us at Profound Treatment!

Position Summary

The Documentation Quality & Compliance Specialist ensures that all client medical, clinical, and administrative records meet Profound Treatment’s documentation standards as well as state, federal, accreditation, and payer requirements. This position is responsible for auditing charts, identifying deficiencies, implementing corrective actions, and training staff on documentation best practices. The role collaborates closely with Clinical, Medical, Admissions, Billing, and Operations teams to reduce compliance risk and support accurate reimbursement.

Key Responsibilities

Chart Auditing & Quality Assurance

Conduct routine and targeted audits of client charts, including intakes, assessments, ASAMs, treatment plans, progress notes, group notes, medical documentation, discharge records, and risk assessments.

Ensure compliance with internal standards, regulatory and accreditation requirements, and payer expectations.

Identify and track missing, late, incomplete, or non-compliant documentation.

Verify documentation supports medical necessity and level of care.

Corrective Action & Risk Mitigation

Identify trends and deficiencies across programs and staff.

Develop and implement corrective action plans; track follow-up and improvement.

Escalate significant compliance concerns to leadership.

Collaborate with Billing and UR teams to reduce audit risk and insurance denials.

Training & Staff Development

Lead documentation training for clinical, medical, and program staff.

Provide ongoing coaching and real-time feedback.

Support onboarding and retraining on workflows and charting standards.

Assist with staff competency related to documentation and compliance.

Systems & Reporting

Utilize the EHR (KIPU preferred) and internal audit tools to log findings and follow-up.

Maintain organized audit records and generate regular performance reports.

Track documentation quality metrics and trends.

Support continuous quality improvement initiatives.

Collaboration

Work closely with Clinical Directors, Program Directors, Medical Staff, Billing, UR, and Operations.

Participate in compliance and quality improvement meetings.

Perform other duties as assigned.

Qualifications

Minimum 2 years’ experience in behavioral health, SUD treatment, healthcare documentation, or auditing.

Strong understanding of clinical documentation, medical necessity, and payer requirements.

Familiarity with accreditation standards (DHCS, CARF, Joint Commission preferred).

Experience with EHR systems (KIPU strongly preferred).

Background in clinical, medical, UR, QA, or compliance preferred.

Skills

Exceptional attention to detail and analytical abilities

Strong written and verbal communication skills

Ability to deliver constructive, professional feedback

Strong organizational and time-management skills

Ability to work independently in a hybrid role

Comfortable leading trainings and addressing deficiencies

High professionalism, discretion, and integrity

Work Environment & Physical Requirements

Ability to sit for long periods while reviewing electronic records.

Use of computer and standard office equipment.

Occasional on-site meetings or trainings.

Work involves confidential client information and interaction with multidisciplinary teams.

Benefits:

Health, Dental, Vision

PTO

Sick

Professional Development assistance

Tuition reimbursement program

Life insurance, AD&D, Employee Assistance Program

Join our team and make a meaningful impact on the lives of those in recovery. Apply today!