Quality Improvement Specialist
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What you'll do
- Conducting comprehensive clinical and documentation reviews of behavioral health claims prior to payment to ensure services meet medical necessity, regulatory, contractual, and billing requirements.
- Evaluating clinical records, validates service delivery, identifies documentation deficiencies, and recommends claim payment, denial, or additional review as appropriate.
- Collaborating 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.
What they're looking for
- 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 have
- Registered Nurse (preferred)
- Licensed Mental Health Professional (preferred) including LCSW, LPC, LMFT, BCBA, LMHP or equivalent
- Knowledge of claims processing, billing practices, coding, and modifier requirements (preferred)
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
City/State
Norfolk, VAWork Shift
First (Days)Overview:
Sentara Health is looking to hire a Remote Quality Improvement Specialist.
This is a remote position: Remote opportunities available in the following states: Virginia, North Carolina, Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington (state), West Virginia, Wisconsin, Wyoming
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.
Knowledge, Skills, and Abilities
- 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.
- Knowledge of claims processing, billing practices, coding, and modifier requirements (preferred).
- 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.
Education:
- Bachelor's degree in health administration or health-related field (required)
Certification:
- 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
Experience:
- 2 years working with (cumulatively) Medicaid, Managed Care, CMS, NCQA Health Plan Standard(required)
- 2 years Quality Improvement (required)
Keywords: Talroo- Health, RN, Licensed Mental Health Professional, LCSW, LPC, LMFT, BCBA, LMHP, Behavioral Health Auditor

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay range for full-time employment is $73,881.60 - $122,532.80 annually.

Additional compensation may be available for this role, such as shift differentials, standby/on-call pay, overtime, shift premiums, extra-shift incentives, or bonus opportunities. Compensation within the range may vary based on qualifications, experience, location, market conditions, and business needs. Note: If an annual salary is posted, it is based on a full-time colleague working 2,080 hours annually.
Benefits: Caring For Your Family and Your Career
• 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
•Colleagues have the opportunity to earn an annual discretionary bonus if established system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission “to improve health every day,” this is a tobacco-free environment.
For positions that are available as remote work, Sentara Health employs associates in the following states:
Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
Company
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