Quality Improvement Specialist
About The Position
Sentara Health is looking to hire a Remote Quality Improvement Specialist. This is a remote position available in multiple states. The Quality Improvement Specialist is responsible for conducting comprehensive clinical and documentation reviews of behavioral health claims prior to payment to ensure services meet medical necessity, regulatory, contractual, and billing requirements. This position evaluates clinical records, validates service delivery, identifies documentation deficiencies, and recommends claim payment, denial, or additional review as appropriate. The reviewer collaborates with providers, clinical teams, compliance departments, and claims operations to ensure accurate reimbursement and adherence to state and federal regulations, Medicaid requirements, and organizational policies.
Requirements
- Strong understanding of behavioral health diagnoses, treatment modalities, and levels of care.
- Knowledge of Medicaid behavioral health regulations and medical necessity criteria.
- Ability to interpret clinical records and apply regulatory standards.
- Excellent critical thinking and investigative skills.
- Ability to make objective, evidence-based determinations.
- Strong written and verbal communication skills.
- Proficiency with Microsoft Office applications and audit tracking systems.
- Bachelor's degree in health administration or health-related field (required)
- 2 years working with (cumulatively) Medicaid, Managed Care, CMS, NCQA Health Plan Standard (required)
- 2 years Quality Improvement (required)
Nice To Haves
- Knowledge of claims processing, billing practices, coding, and modifier requirements (preferred).
- Registered Nurse (preferred)
- Licensed Mental Health Professional (preferred) any of the listed below may be considered: Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Board Certified Behavioral Analyst (BCBA), Licensed Mental Health Professional (LMHP) or equivalent
Responsibilities
- Conduct comprehensive clinical and documentation reviews of behavioral health claims prior to payment to ensure services meet medical necessity, regulatory, contractual, and billing requirements.
- Evaluate clinical records, validate service delivery, and identify documentation deficiencies.
- Recommend claim payment, denial, or additional review as appropriate.
- Collaborate with providers, clinical teams, compliance departments, and claims operations to ensure accurate reimbursement and adherence to state and federal regulations, Medicaid requirements, and organizational policies.
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
- Pet Insurance
- Legal Resources Plan
- Annual discretionary bonus if established system and employee eligibility criteria is met.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
