QA QI Clinician- DMC-ODS

The CalMHSA Way:

• Curiosity
• Innovation
• Grounded in Mission
• Ownership
• Clarity

SUMMARY: The Quality Management Clinician supports CalMHSA’s regional Drug Medi-Cal Organized Delivery System (DMC-ODS) administrative model by providing clinical leadership for quality management, utilization management, provider compliance, and care delivery oversight activities. This position works closely with County Behavioral Health Plans, providers, CalMHSA staff, and state partners to support clinically informed implementation of DMC-ODS requirements, with a strong focus on service authorization, medical necessity review, provider network quality, access standards, care coordination, quality improvement, and performance improvement activities.

This role requires strong knowledge of DMC-ODS requirements, Medi-Cal behavioral health managed care, ASAM criteria, substance use disorder treatment systems, and county behavioral health plan operations. The Quality Management Clinician will provide clinical input into policies, procedures, practice guidelines, training expectations, provider-facing operations, and quality improvement strategies to help ensure services are clinically appropriate, accessible, compliant, and aligned with state and federal requirements.

DUTIES AND RESPONSIBILITIES include but are not limited to:

• Conduct clinical service authorization, reauthorization, and medical necessity reviews for delegated DMC-ODS functions, including residential and withdrawal management services, as applicable.
• Apply ASAM criteria, DMC-ODS requirements, Medi-Cal medical necessity standards, and parity considerations to clinical review and utilization management activities.
• Provide clinical consultation on access, screening, referral, care coordination, placement, transitions between levels of care, and residential step-down planning.
• Develop and review clinical policies, procedures, practice guidelines, training expectations, and clinical workflow standards for delegated DMC-ODS functions.
• Provide clinical leadership for provider onboarding, implementation support, and provider-facing operations related to access, screening, documentation, care coordination, and service delivery expectations.
• Oversee clinical components of provider credentialing/recredentialing standards, including review of provider qualifications, scope of services, and clinical service capacity.
• Lead clinical quality improvement activities, including QI Work Plan development, PIP coordination, clinical trend review, and development of clinically informed improvement strategies.
• Review utilization, access, grievance, provider performance, and quality data to identify clinical risks, gaps in care, and opportunities for improvement.
• Provide clinical input into provider monitoring, site reviews, chart reviews, corrective action plans, and follow-up related to clinical quality or service delivery concerns.
• Provide training and technical assistance to counties, providers, and internal teams on DMC-ODS clinical requirements, ASAM criteria, medical necessity, documentation expectations, and care coordination standards.
• Represent CalMHSA in clinical quality, utilization management, provider, county, EQRO, DHCS, and other stakeholder meetings, as assigned.
• This position will have access to various applications that house confidential information related to consumer demographics and behavioral health; ensure that access is used responsibly, maintaining the integrity and security of systems while preventing accidental or malicious misuse.
• Perform other duties as assigned, demonstrating flexibility and commitment to organizational success.

BACKGROUND CHECK ELIGIBLE DUTIES

This position will have access to various applications that house confidential information, including county behavioral health records, Protected Health Information (PHI), substance use disorder treatment records, consumer demographic data, clinical documentation, utilization management records, provider compliance files, and quality management documentation. The incumbent must handle all confidential information in accordance with HIPAA Privacy and Security Rules, 42 CFR Part 2 regulations, applicable state confidentiality requirements, and CalMHSA security policies, ensuring that access is used responsibly while maintaining the integrity and security of systems and preventing accidental or malicious misuse.

Qualifications

An acceptable equivalent combination of education, experience, and skill may be considered.

EDUCATION/EXPERIENCE:

• Master’s degree in Social Work, Marriage and Family Therapy, Professional Clinical Counseling, Psychology, or related clinical field, required.
• Current California Board of Behavioral Sciences (BBS) licensure or license eligibility required; acceptable credentials may include LMFT, LCSW, LPCC, AMFT, ACSW, APCC, or equivalent BBS-recognized status.
• Minimum of three (3) years of experience in behavioral health, substance use disorder treatment, quality management, utilization management, clinical program oversight, or a closely related field, required.
• Experience with DMC-ODS, including ASAM criteria, medical necessity, authorization processes, residential treatment, withdrawal management, care coordination, and Medi-Cal documentation requirements, strongly preferred.
• Experience working within or directly with a County Behavioral Health Plan, particularly overseeing or supporting DMC-ODS functions, strongly preferred.
• Experience with provider monitoring, credentialing/recredentialing, site reviews, chart reviews, quality improvement, EQRO, PIPs, or corrective action processes, preferred.

SKILLS AND ATTRIBUTES:

• Strong clinical knowledge of substance use disorder treatment, DMC-ODS services, ASAM criteria, medical necessity, care coordination, and transitions between levels of care.
• Strong understanding of California county behavioral health plan operations, Medi-Cal managed care requirements, and DMC-ODS contract requirements.
• Ability to conduct clinical review and apply regulatory, contractual, and clinical standards to authorization, quality, provider monitoring, and compliance activities.
• Excellent written and verbal communication skills, including the ability to develop clear clinical guidance, training materials, reports, and policy/procedure documents.
• Ability to work effectively with county leaders, providers, clinical staff, state partners, and internal cross-functional teams.
• Strong facilitation, technical assistance, and provider engagement skills.
• Ability to analyze clinical, quality, access, utilization, and performance data to identify trends and recommend improvement strategies.
• Strong organizational skills and ability to manage multiple projects, deadlines, and stakeholder expectations.
• Ability to exercise sound clinical judgment, maintain confidentiality, and communicate sensitive information professionally.

COMPUTER SKILLS: Demonstrate the ability to use a computer and applicable computer software effectively. Intermediate knowledge of Excel & Word, PowerPoint, Adobe, and Outlook required. Experience with electronic health records, utilization management platforms, provider management systems, or data/reporting systems preferred.

LANGUAGE SKILLS AND MATHEMATICAL SKILLS: Demonstrate the ability to read, comprehend, and respond appropriately through written or verbal form; demonstrate tactfulness when communicating with internal staff, counties, providers, state partners, and other stakeholders. Ability to communicate effectively with a variety of audiences. Ability to add, subtract, multiply, and divide in all measure units, using whole numbers, common fractions, and decimals.

REASONING: Demonstrate the ability to effectively apply clinical judgment, regulatory requirements, and common sense to daily tasks; demonstrate the ability to work independently with limited supervision; demonstrate excellent analytical and critical thinking skills; demonstrate the ability to conduct research, ask appropriate probing questions, identify risks, and develop practical solutions.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is frequently required to sit and stand; use phone and headset; use hands, arms, finders to type; answer phones; write; use calculator; demonstrate strength to lift and carry materials weighing up to 10 pounds; demonstrate clear vision to read printed materials and a computer screen; hearing and speech to communicate in person and over the telephone.

SENSORY DEMANDS: The incumbent must spend long hours in intense concentration. The incumbent must also spend long hours on the computer entering information which requires attention to detail and high levels of accuracy.

MENTAL DEMANDS: There are a number of deadlines associated with this position, which may cause significant pressure. The incumbent must also attend to a wide variety of individuals regarding various topics/challenges.

REGULAR WORK SCHEDULE: Schedule varies depending on business needs; however, regular company business hours are 8:00am to 5:00pm, Monday – Friday.