Remote Behavioral Health Quality Improvement Specialist

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

Benefits offered by this job

Medical, Dental, Vision plans

401k/403B with employer match

Paid time off

Tuition Assistance

Student Debt Pay Down

Life Insurance

Disability insurance

Bonus opportunities

Job summary

Sentara Health in Norfolk, VA is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and regulatory compliance. This position supports accurate reimbursement by evaluating clinical records and guiding payment or denial decisions.

The role requires a Bachelor's in health administration, with RN or LMHP preferred, and at least 2 years of Medicaid/Managed Care and 2 years in Quality Improvement.

Qualifications

• 2 years Medicaid/Managed Care/CMS/NCQA Health Plan Standard experience
• 2 years Quality Improvement experience
• Bachelor's degree required; RN preferred; LMHP/LCSW/LPC/BCBA options considered

Responsibilities

• Conduct clinical and documentation reviews of behavioral health claims prior to payment
• Evaluate records, validate service delivery, identify deficiencies and recommend actions
• Collaborate with providers, clinical teams, compliance, and claims operations
• Ensure compliance with state/federal regulations and Medicaid requirements

Skills

Behavioral health knowledge

Medicaid regulations

Regulatory interpretation

Billing & coding knowledge

Critical thinking

Evidence-based decision making

Communication skills

Office & audit systems

Education

Bachelor's degree in health administration

Tools

Microsoft Office

Audit tracking systems

Job description

Sentara Health in Norfolk, VA is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and regulatory compliance. This position supports accurate reimbursement by evaluating clinical records and guiding payment or denial decisions.

The role requires a Bachelor's in health administration, with RN or LMHP preferred, and at least 2 years of Medicaid/Managed Care and 2 years in Quality Improvement.