Quality Improvement Specialist
Sentara Health
Summary
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.
Job description
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.
Requirements
- 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)
- Registered Nurse (preferred)
- Licensed Mental Health Professional (preferred): LCSW, LPC, LMFT, BCBA, LMHP or equivalent
Benefits
- Medical, Dental & Vision
- Adoption, Fertility & Surrogacy Reimbursement
- Paid Time Off & Sick Leave
- Paid Parental & Family Caregiver Leave
- Emergency Backup Care
- Long-Term & Short-Term Disability
- Critical Illness Plans
- Life Insurance
- 401k/403B with Employer Match
- Tuition Assistance
- Student Debt Pay Down
- Pet Insurance
- Legal Resources Plan
- Annual Discretionary Bonus
Company overview
Sentara Health is a leading not-for-profit integrated healthcare delivery system serving Virginia, northeastern North Carolina, and Florida. Founded in 1888 and headquartered in Hampton Roads, Virginia, Sentara operates 12 acute care hospitals across its service area, with 10 hospitals holding prestigious Magnet® recognition for nursing excellence. The organization employs approximately 34,000 healthcare professionals and serves over 1 million health plan members through its Sentara Health Plans division. As one of the top 20 largest not-for-profit integrated health systems in the United States, Sentara is nationally recognized for clinical quality, safety, and innovation. The system has received numerous accolades including Health Quality Innovator of the Year (2024), Forbes' "America's Best-In-State Employer" (2024), and inclusion in IBM Watson Health's "Top 15 Health Systems." Sentara's comprehensive services span hospital care, outpatient facilities, home health, hospice services, and specialized programs like the Nightingale air ambulance service, which has completed over 20,000 missions since 1982.