Remote Behavioral Health QA and Compliance Specialist

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

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Life Insurance

401(k) with employer match

Paid time off

Parental leave

Educational assistance

Student loan repayment

Bonuses if eligible

Job summary

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and regulatory compliance. This is a fully remote role with opportunities across multiple states, including Oklahoma.

You will evaluate clinical records, identify documentation gaps, and collaborate with providers, compliance teams, and claims operations to ensure accurate reimbursement and adherence to Medicaid requirements and internal policies.

Qualifications

• Bachelor's degree in health administration or related field.
• Two years of Medicaid/Managed Care/CMS/NCQA Health Plan Standard experience.
• Two years of Quality Improvement experience.
• RN or licensed mental health professional preferred.

Responsibilities

• Conduct comprehensive clinical and documentation reviews of behavioral health claims for medical necessity, regulatory, contractual, and billing compliance.
• Collaborate with providers, clinical teams, compliance, and claims operations to ensure accurate reimbursement and adherence to regulations.

Skills

Behavioral health knowledge

Medicaid regulations

Clinical records interpretation

Claims processing knowledge

Critical thinking

Evidence-based decisions

Written communication

Verbal communication

Audit tracking systems

Microsoft Office

Education

Bachelor's degree in health administration

RN license preferred

Licensed Mental Health Professional preferred

Tools

Microsoft Office

Job description

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and regulatory compliance. This is a fully remote role with opportunities across multiple states, including Oklahoma.

You will evaluate clinical records, identify documentation gaps, and collaborate with providers, compliance teams, and claims operations to ensure accurate reimbursement and adherence to Medicaid requirements and internal policies.