Quality Improvement Specialist

Sentara Health Administration, Inc.; Norfolk (VA); Remote; USD 74,000 - 123,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with employer match

Paid Time Off and Sick Leave

Paid Parental & Family Caregiver Leave

Student Debt Pay Down

Tuition Assistance

Job summary

Sentara Health seeks a Remote Quality Improvement Specialist to conduct clinical and documentation reviews of behavioral health claims to ensure medical necessity and regulatory compliance. This role collaborates with providers and compliance teams to ensure accurate reimbursement and adherence to Medicaid and NCQA standards.

The position requires a bachelor’s in health administration or related field, with 2+ years in Medicaid/Managed Care and 2+ years in Quality Improvement.

Qualifications

• Bachelor's degree in health administration or health-related field required.
• 2 years experience with Medicaid/Managed Care/CMS/NCQA Health Plan Standards required.
• 2 years in Quality Improvement required.

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/review.
• Collaborate with providers, clinical teams, compliance, and claims to ensure accurate reimbursement and regulatory adherence.

Skills

Medicaid knowledge

CMS regulations

NCQA standards

Audit & review

Regulatory interpretation

Communication

Microsoft Office

Audit tracking systems

Education

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

RN license (preferred)

Licensed Mental Health Professional (preferred)

Tools

Microsoft Office

Audit tracking systems

Job description

City/StateNorfolk, VAWork ShiftFirst (Days)Overview: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, WyomingThe 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 AbilitiesStrong 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 equivalentExperience: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 AuditorWe provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $73,881.60 - $122,532.80 annually. Additional compensation may be available for this role, such as shift differentials, standby/on-call pay, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually. Sentara offers a comprehensive benefits package, including medical, dental, vision, life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation, sick time, and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.Benefits: Caring For Your Family and Your Career• Medical, Dental, Vision plans• Adoption, Fertility and Surrogacy Reimbursement up to $10,000• Paid Time Off and Sick Leave• Paid Parental & Family Caregiver Leave• Emergency Backup Care• Long-Term, Short-Term Disability, and Critical Illness plans• Life Insurance• 401k/403B with Employer Match• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education• Student Debt Pay Down – $10,000•Pet Insurance•Legal Resources Plan•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.In support of our mission “to improve health every day,” this is a tobacco-free environment.For positions that are available as remote work, Sentara Health employs associates in the following states:Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.