Remote Behavioral Health QA and Claims Auditor

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 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.