Remote Quality Improvement Specialist - Behavioral Health

Sentara Health; Virginia; 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

Job summary

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims before payment, ensuring medical necessity, regulatory compliance, and proper billing practices across remote opportunities in multiple states.

The role requires 2 years of Medicaid/Quality Improvement experience and a health administration degree. RN or LMHP credentials are preferred, with Sentara offering competitive pay and a comprehensive benefits package.

Qualifications

• Bachelor's degree in health administration or health-related field required.
• 2 years with Medicaid/Managed Care/CMS/NCQA Health Plan Standard
• 2 years Quality Improvement experience
• RN preferred or related mental health credentials may be considered

Responsibilities

• Conduct comprehensive clinical and documentation reviews of behavioral health claims prior to payment to ensure medical necessity and compliance.
• Evaluate clinical records, validate service delivery, identify documentation deficiencies, and recommend payment, denial, or additional review.
• 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

Written/verbal communication

Microsoft Office proficiency

Education

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

Job description

Sentara Health is seeking a Remote Quality Improvement Specialist to review behavioral health claims before payment, ensuring medical necessity, regulatory compliance, and proper billing practices across remote opportunities in multiple states.

The role requires 2 years of Medicaid/Quality Improvement experience and a health administration degree. RN or LMHP credentials are preferred, with Sentara offering competitive pay and a comprehensive benefits package.