Clinical Documentation & QA Specialist

We are looking for a highly detail-oriented and organised Clinical Documentation & QA Specialist to review clinical documentation, identify errors or gaps, and ensure records meet required quality and compliance standards.

This is a hands-on quality assurance role where you will work closely with RBTs, BCBAs, and other providers to review documentation, coordinate corrections, and ensure issues are resolved accurately and on time.

The ideal candidate is patient, thorough, and confident providing constructive feedback. You should be comfortable dealing with pushback and difficult conversations while remaining professional and not taking things personally.

Key Responsibilities

• Set up employee and provider profiles within company systems.
• Use AI tools to identify session notes that may not meet funder expectations and review flagged issues.
• Conduct documentation audits against approved standards and procedures.
• Review RBT and BCBA notes for:
• Missing goals
• Incomplete or overly similar narratives
• Signature issues
• Incorrect dates or times
• Compare documentation against CentralReach billing, service records, and schedules to identify discrepancies.
• Coordinate corrections with providers and follow up on outstanding changes.
• Maintain an accurate audit trail within assigned permissions.
• Maintain Excel trackers for new-RBT reviews, recurring errors, amended or removed notes, and unresolved corrections.
• Review parent/caregiver training utilisation, including service code 97156, against payer-specific expectations and follow up with BCBAs where required.
• Support profile, note, and timesheet administration.
• Assist with CentralReach mobile workflow testing and report system issues.
• Train new hires on proper documentation practices and support consistent documentation standards.

What We're Looking For

• Extremely detail-oriented and thorough.
• Highly organised with strong follow-through.
• Patient and comfortable working through repetitive documentation reviews.
• A quick learner who can understand and apply guidance independently.
• Confident providing constructive feedback and following up when corrections are required.
• Comfortable dealing with resistance or pushback without taking it personally.
• Able to identify inconsistencies, errors, and missing information accurately.
• Strong in written communication and professional when communicating with providers.
• Comfortable working with confidential records and sensitive information.
• Proficient in Excel and Microsoft Office.

Experience & Qualifications

Healthcare experience or previous CentralReach experience is not required and training can be provided.

However, the following would be advantageous:

• Experience in healthcare, clinical administration, quality assurance, or documentation review.
• Experience with clinical or medical records.
• Familiarity with ABA terminology or clinical documentation.
• Experience with CentralReach or similar healthcare/clinical systems.
• Higher education in psychology, healthcare, medical, clinical, or a related field.

No specific clinical licence or mandatory qualification is required.

Software & Tools

• Microsoft Excel
• Microsoft Word
• SharePoint
• Outlook
• Microsoft Teams
• Zoom
• CentralReach – training provided
• CentralReach mobile – workflow testing

Important Expectations

This role requires someone who can stand their ground professionally. You will occasionally deal with RBTs, BCBAs, or other providers who may be frustrated or push back when documentation needs to be corrected. The right person needs to be able to remain calm, objective, and professional, focus on the requirements, and not take difficult interactions personally.

If you enjoy quality assurance, spotting details others may miss, keeping records accurate, and helping teams improve their documentation, this could be a great fit.