Remote Behavioral Health Claims QA Specialist

Sentara Health; Nevada; Remote; USD 74,000 - 123,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) match

PTO

Tuition assistance

Student debt payoff

Life insurance

Disability coverage

Parental leave

Job summary

Sentara Health is seeking a Remote Quality Improvement Specialist to conduct clinical and documentation reviews of behavioral health claims before payment, ensuring medical necessity and regulatory compliance. In this remote role, you will collaborate with providers, clinical teams, and compliance to improve reimbursement accuracy, study Medicaid requirements, and support organizational policies.

A Bachelor's degree is required, with 2+ years in Medicaid/QA and RN or mental health licensure

Qualifications

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

Responsibilities

• Conduct comprehensive clinical and documentation reviews of behavioral health claims prior to payment.
• Evaluate clinical records, validate service delivery, and identify documentation deficiencies.
• Recommend claim payment, denial, or additional review as appropriate.
• Collaborate with providers, clinical teams, compliance, and claims operations to ensure accurate reimbursement.

Skills

Behavioral health

Medicaid rules

Clinical record interpretation

Documentation auditing

Regulatory knowledge

Communication skills

MS Office

Education

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

Tools

Audit tracking systems

Microsoft Office

Job description

Sentara Health is seeking a Remote Quality Improvement Specialist to conduct clinical and documentation reviews of behavioral health claims before payment, ensuring medical necessity and regulatory compliance. In this remote role, you will collaborate with providers, clinical teams, and compliance to improve reimbursement accuracy, study Medicaid requirements, and support organizational policies.

A Bachelor's degree is required, with 2+ years in Medicaid/QA and RN or mental health licensure