Remote Behavioral Health QI Specialist

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

Benefits offered by this job

Health insurance

401k/403B with employer match

Paid time off

Job summary

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and compliance. The role supports reimbursement accuracy by evaluating records, identifying deficiencies, and recommending actions with cross-department collaboration.

Ideal candidates have 2+ years in Medicaid/Managed Care and 2+ years in Quality Improvement; RN or LMHP preferred. Remote work available in multiple states including Florida.

Qualifications

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

Responsibilities

• Conduct clinical and documentation reviews of behavioral health claims to ensure medical necessity.
• Evaluate clinical records and determine claim payment, denial, or further review.
• Collaborate with providers, clinical teams, compliance, and claims operations to ensure accurate reimbursement.
• Ensure compliance with state and federal regulations and Medicaid requirements.

Skills

Behavioral health knowledge

Regulatory knowledge

Critical thinking

Communication skills

Microsoft Office

Education

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

Tools

Audit tracking systems

Job description

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and compliance. The role supports reimbursement accuracy by evaluating records, identifying deficiencies, and recommending actions with cross-department collaboration.

Ideal candidates have 2+ years in Medicaid/Managed Care and 2+ years in Quality Improvement; RN or LMHP preferred. Remote work available in multiple states including Florida.