Quality Improvement Specialist

Sentara Healthcare Inc; Norfolk (VA); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity, ensuring compliance and accurate reimbursement. The role collaborates with providers, clinical teams, and compliance to maintain regulatory standards.

Ideal candidates have 2+ years in Medicaid/Managed Care and 2+ years in Quality Improvement, with a Bachelor’s in health administration or related field; RN or LMHP preferred. This is a remote role with national scope.

Qualifications

• Bachelor's degree in health administration or health-related field required.
• 2 years Medicaid, Managed Care, CMS, or NCQA Health Plan Standard experience required.
• 2 years Quality Improvement experience required.
• RN preferred or Licensed Mental Health Professional preferred.

Responsibilities

• Conduct comprehensive clinical and documentation reviews of behavioral health claims prior to payment.
• Evaluate clinical records, validate service delivery, identify documentation deficiencies, and recommend payment, denial, or further review.
• Collaborate with providers, clinical teams, compliance, and claims operations to ensure accurate reimbursement and regulatory adherence.

Skills

Behavioral Health Knowledge

Medicaid Regulations

Medical Necessity Criteria

Claims Processing & Billing

Audit & Documentation Review

Critical Thinking

Communication Skills

Microsoft Office

Audit Tracking Systems

Education

Bachelor's degree in health administration or health-related field

Tools

Audit Tracking Systems

Microsoft Office

Job description

Sentara Health is looking to hire a Remote Quality Improvement Specialist.

This is a remote position: Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming

The Quality Improvement Specialist is responsible for conducting comprehensive clinical and documentation reviews of behavioral health claims prior to payment to ensure services meet medical necessity, regulatory, contractual, and billing requirements. This position evaluates clinical records, validates service delivery, identifies documentation deficiencies, and recommends claim payment, denial, or additional review as appropriate.

The reviewer collaborates with providers, clinical teams, compliance departments, and claims operations to ensure accurate reimbursement and adherence to state and federal regulations, Medicaid requirements, and organizational policies.

Knowledge, Skills, and Abilities

• Strong understanding of behavioral health diagnoses, treatment modalities, and levels of care.
• Knowledge of Medicaid behavioral health regulations and medical necessity criteria.
• Ability to interpret clinical records and apply regulatory standards.
• Knowledge of claims processing, billing practices, coding, and modifier requirements (preferred).
• Excellent critical thinking and investigative skills.
• Ability to make objective, evidence-based determinations.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office applications and audit tracking systems.

Education:

• Bachelor's degree in health administration or health-related field (required)

Certification:

• Registered Nurse (preferred)

Licensed Mental Health Professional (preferred) any of the listed below may be considered:

• Licensed Clinical Social Worker (LCSW)
• Licensed Professional Counselor (LPC)
• Licensed Marriage and Family Therapist (LMFT)
• Board Certified Behavioral Analyst (BCBA)
• Licensed Mental Health Professional (LMHP) or equivalent

Experience:

• 2 years working with (cumulatively) Medicaid, Managed Care, CMS, NCQA Health Plan Standard(required)
• 2 years Quality Improvement (required)

Keywords: Talroo- Health, RN, Licensed Mental Health Professional, LCSW, LPC, LMFT, BCBA, LMHP, Behavioral Health Auditor

Sentara is currently reviewing market compensation for this role. Our Talent Acquisition team will be able to share more specific information during the recruiting process.