Quality Improvement Specialist

City/State

Norfolk VA

Work 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:

• Bachelors 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 $73881.60 - $122532.80 annually. Additional compensation may be available for this role such as shift differentials standby/on-call pay 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 2080 hours annually. Sentara offers a comprehensive benefits package including medical dental vision life and disability insurance; 401(k)/403(b) with employer match; paid time off (vacation sick time and holidays); paid parental and military leave; educational assistance or student loan repayment; and voluntary benefits.

Benefits: Caring For Your Family and Your Career

Medical Dental Vision plans

Adoption Fertility and Surrogacy Reimbursement up to $10000

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 $5250/year and discounted educational opportunities through Guild Education

Student Debt Pay Down $10000

Pet Insurance
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus ifestablished 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 30000-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.