Yahye Ismail

Documentation & Billing Integrity

• Audit clinical and caregiver notes daily to ensure 100% alignment with Individualized Treatment Plans (ITP) and authorized service hours.
• Reconcile visit logs with billing records to prevent overbilling, underbilling, or Medicaid/insurance recoupment.
• Verify document accuracy, including timestamps, signatures, and goal-tracking, ensuring all notes meet state and federal compliance standards.

Staff Training & Development

• Onboard and train new field staff on agency-specific documentation standards, HIPAA privacy rules, and Electronic Visit Verification systems.
• Conduct 1-on-1 coaching sessions with caregivers to improve the clinical quality and "billability" of their daily progress notes.
• Develop training materials and reference guides to streamline the documentation process for field staff.

Compliance & Audit Readiness

• Monitor ITP compliance by ensuring that services provided directly match the client's specific medical and behavioral goals.
• Maintain audit-ready files for state, Medicaid, and private insurance reviews, reducing the risk of administrative penalties.
• Collaborate with management to implement Corrective Action Plans when documentation trends show recurring errors.

• Reviewed session notes and clinical documentation to ensure compliance with DHS and EIDBI regulations
• Conducted internal audits to identify documentation errors and improve compliance standards
• Trained staff on ABA principles, documentation requirements, and regulatory expectations
• Monitored service delivery to ensure alignment with Individual Treatment Plans (ITPs)
• Identified compliance issues and provided corrective feedback to staff and leadership
• Maintained accurate records to support audits and external reviews
• Collaborated with clinical and administrative teams to ensure quality and compliant care
• Led training sessions for new staff on compliance and ABA implementation
• Improved documentation accuracy by identifying and correcting recurring errors