Remote Behavioral Health Quality Improvement Specialist

Sentara Health; Richmond (VA); Remote; USD 74,000 - 123,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Fertility and Surrogacy reimbursement

Paid Time Off and Sick Leave

Parental & Family caregiver leave

Long-Term/Short-Term disability and OD

401k with employer match

Tuition assistance

Student debt paydown

Pet Insurance

Legal resources plan

Job summary

Sentara Health in Norfolk, VA, seeks a Remote Quality Improvement Specialist. This full-time, remote role offers opportunities across multiple states to review behavioral health claims for medical necessity and regulatory compliance.

You will evaluate clinical records, identify documentation gaps, and work with providers, compliance, and claims teams to ensure accurate reimbursement and adherence to state and federal regulations.

Qualifications

• Bachelor's degree in health administration or health-related field is required.
• 2 years working with Medicaid/Managed Care/CMS/NCQA Health Plan Standard is required.
• 2 years Quality Improvement experience is required.

Responsibilities

• Conduct comprehensive clinical and documentation reviews of behavioral health claims prior to payment to ensure medical necessity and regulatory compliance.
• Identify documentation deficiencies and recommend claim payment, denial, or additional review.
• Collaborate with providers, clinical teams, compliance, and claims operations to ensure accurate reimbursement.

Skills

Behavioral health knowledge

Medicaid regulations

Clinical record review

Claims processing knowledge

Critical thinking

Communication skills

MS Office proficiency

Audit tracking systems

Education

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

Tools

Audit tracking systems

Job description

Sentara Health in Norfolk, VA, seeks a Remote Quality Improvement Specialist. This full-time, remote role offers opportunities across multiple states to review behavioral health claims for medical necessity and regulatory compliance.

You will evaluate clinical records, identify documentation gaps, and work with providers, compliance, and claims teams to ensure accurate reimbursement and adherence to state and federal regulations.