Hiring: Quality Improvement Specialist Company: Sentara Health Location: Norfolk, VA Job Posted Time: 2026-09-12 11:49:58 Employment Type: Full-time / Remote Target Skills & Keywords : Medicaid, Microsoft Office About the job Experience: •2 years working with (cumulatively) Medicaid, Managed Care, CMS, NCQA Health Plan Standard(required) •2 years Quality Improvement (required) •Paid Time Off and Sick Leave •Paid Parental & Family Caregiver Leave Required Skills: •Lead and oversee conducting comprehensive clinical and documentation reviews of behavioral health claims prior to payment to ensure services meet medical necessity, regulatory, contractual, and billing requirements. Qualifications: •In-depth knowledge of behavioral health diagnoses, treatment modalities, and levels of care. •Knowledge of Medicaid behavioral health regulations and medical necessity criteria. •Demonstrated capacity 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. •Demonstrated capacity 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) •Licensed Clinical Social Worker (LCSW) Compensation: •$73,881 - $122,532 / year •Flexible work environment (work from home / hybrid options) •Adoption, Fertility and Surrogacy Reimbursement up to $10,000 Interested candidates, please apply directly through the job posting on company's career page or try via AI auto apply on this platform. Don't miss this opportunity to join a forward-thinking team!