Remote Behavioral Health Quality Improvement Specialist

Sentara Health; Utah; 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 & Holidays

Paid Parental & Family Caregiver Leave

Student Debt Pay Down

Tuition Assistance

Job summary

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims for medical necessity and regulatory compliance. This role supports collaboration with providers and clinical teams to ensure accurate reimbursement across multiple states.

The position offers a remote work model with competitive compensation and comprehensive benefits. Requirements include a bachelor's degree in health administration or related field, and experience in Medicaid/Quality

Qualifications

• Bachelor's degree in health administration or health-related field required.
• 2 years Medicaid/Managed Care experience and 2 years Quality Improvement experience required.
• RN or Licensed Mental Health Professional credentials preferred (LCSW/LPC/LMFT/BCBA/LMHP).
• Knowledge of billing, coding, and medical necessity criteria preferred.

Responsibilities

• Conduct clinical and documentation reviews of behavioral health claims prior to payment to ensure medical necessity and compliance.
• Evaluate records, identify 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

Interpret clinical records

Claims processing & coding

Critical thinking

Evidence-based decision making

Written & verbal communication

MS Office & audit 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 and regulatory compliance. This role supports collaboration with providers and clinical teams to ensure accurate reimbursement across multiple states.

The position offers a remote work model with competitive compensation and comprehensive benefits. Requirements include a bachelor's degree in health administration or related field, and experience in Medicaid/Quality