Clinical Practice Analyst in Southwest Virginia (Bristol, Roanoke)

Sentara Health • Bristol, VA

4d • Hybrid

About The Position

Sentara Health Plans is hiring a Clinical Practice Analyst- RN/LPC/LCSW - Southwest Virginia (Bristol, Roanoke)! Status: Full-time, permanent position (40 hours) Standard working hours: 8am to 5pm EST, M-F Location: Candidate must be located in Southwest Virginia (Bristol, Roanoke). This position will work remotely 4 days per week and 1 day per week visiting providers in Southwest Virginia (Bristol, Roanoke). In-person meetings may be required as needed at the closest office or an agreed-upon location. Job responsibilities: As a Clinical Practice Analyst, you will play a key role in ensuring the integrity and effectiveness of clinical services across multiple lines of business. This position is responsible for conducting comprehensive reviews of clinical documentation, evaluating medical necessity, and monitoring provider compliance with regulatory and contractual standards. Analysts may present findings and recommendations to internal committees and leadership, supporting data-driven decisions that improve care delivery and operational performance. Key Responsibilities: Conduct detailed reviews of clinical documentation for accuracy, completeness, and compliance with state and federal regulations. Assess medical necessity, scope, and duration of services against established guidelines. Identify patterns of outlier activity and escalate concerns for resolution. Prepare clear, actionable reports and present findings to internal committees or leadership as needed. Collaborate with providers to implement corrective actions and education initiatives. Contribute to performance monitoring and reporting to support continuous improvement efforts. Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees. Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals. We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health. Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth. Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve! To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-93864. #Indeed Talroo - Nursing Healthcare, Managed Care, MCO, Health Plan, Virginia Beach, VA, Virginia, Clinical Practice Analyst, Compliance, Provider, regulatory, care delivery, Southwest Virginia, Bristol, Roanoke Sentara Health is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering hundreds of sites of care including 12 hospitals, PACE, home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!

Requirements

• MLD - Master's Level Degree- REQUIRED
• Candidate must have active clinical licensure in the state of Virginia. LPN or RN. Social work candidates required to have active social work licensure - LCSW. Counselor candidates must have appropriate and active licensure LPC. Virginia state requirements for licensure must be met and maintained.
• A minimum of three (3) years of professional experience REQUIRED
• At least one (1) year of quality, regulatory, compliance, accreditation, and/or auditing experience.

Nice To Haves

• Knowledge of clinical regulatory requirements, experience with CMS and state regulatory and accreditation requirements preferred.

Responsibilities

• Conduct detailed reviews of clinical documentation for accuracy, completeness, and compliance with state and federal regulations.
• Assess medical necessity, scope, and duration of services against established guidelines.
• Identify patterns of outlier activity and escalate concerns for resolution.
• Prepare clear, actionable reports and present findings to internal committees or leadership as needed.
• Collaborate with providers to implement corrective actions and education initiatives.
• Contribute to performance monitoring and reporting to support continuous improvement efforts.

Benefits

• Medical, Dental, Vision plans
• Adoption, Fertility and Surrogacy Reimbursement up to $10,000
• Paid Time Off and Sick Leave
• Paid Parental & Family Caregiver Leave
• Emergency Backup Care
• Long-Term, Short-Term Disability, and Critical Illness plans
• Life Insurance
• 401k/403B with Employer Match
• Tuition Assistance – $5,250/year and discounted educational opportunities through Guild Education
• Student Debt Pay Down – $10,000
• Reimbursement for certifications and free access to complete CEUs and professional development
• Pet Insurance
• Legal Resources Plan
• Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level