Quality Improvement Specialist

Sentara Health; Virginia; Hybrid; 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 holidays

Tuition assistance and student debtPay

Disability plans and life insurance

Job summary

Sentara Health seeks a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and regulatory compliance. This remote role supports multiple states and requires a health administration degree with 2+ years in Medicaid/Managed Care and quality improvement.

The ideal candidate will have strong analytical, communication, and auditing skills, and may hold RN or licensed mental health credentials. Sentara offers extensive benefits and remote work flexibility.

Qualifications

• Bachelor's degree in health administration or health-related field.
• RN preferred; LMHP or equivalent preferred.
• 2 years experience with Medicaid/Managed Care and CMS.
• 2 years Quality Improvement experience.

Responsibilities

• Conduct comprehensive clinical and documentation reviews of behavioral health claims prior to payment.
• Evaluate clinical records and validate service delivery.
• Identify documentation deficiencies and recommend payment, denial, or further review.
• Collaborate with providers, clinical teams, compliance, and claims operations.
• Ensure compliance with Medicaid regulations and organizational policies.

Skills

Medicaid knowledge

Regulatory interpretation

Auditing & documentation

Written & verbal communication

Microsoft Office proficiency

Education

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

Registered Nurse (RN) preferred

Licensed Mental Health Professional (preferred)

LCSW/LPC/LMFT/BCBA/LMHP or equivalent

Tools

Audit tracking systems

Claims processing systems

Job description

City/State Norfolk, VA Work Shift First (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, 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

Compensation

We 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, 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.

Sentara Health is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years.

Offering hundreds of sites of care including 12 hospitals, PACE, home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan.

The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years.

U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years.

Sentara offers professional development and a continued employment philosophy!