What are the responsibilities and job description for the Quality Improvement Specialist position at Sentara?
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
Sentara is currently reviewing market compensation for this role. Our Talent Acquisition team will be able to share more specific information during the recruiting process.