Quality Improvement Specialist

About Our Client:
The organization operates within the healthcare industry, focusing on behavioral health services. It addresses the challenge of ensuring behavioral health claims meet medical necessity, regulatory, contractual, and billing requirements before payment. The organization employs a comprehensive review process to validate service delivery, maintain compliance with state and federal regulations, Medicaid requirements, and organizational policies, supporting accurate reimbursement and quality care.
About the Opportunity:
The QUALITY IMPROVEMENT SPECIALIST role is responsible for conducting detailed clinical and documentation reviews of behavioral health claims prior to payment. This position ensures services comply with necessary medical, regulatory, and billing standards. By evaluating clinical records and collaborating with providers and internal teams, the specialist directly impacts the integrity of claim payments and supports adherence to healthcare regulations.
Responsibilities:
Conduct comprehensive clinical and documentation reviews of behavioral health claims prior to payment.
Evaluate clinical records to validate service delivery and identify documentation deficiencies.
Recommend claim payment, denial, or additional review based on findings.
Collaborate with providers, clinical teams, compliance departments, and claims operations.
Ensure adherence to state and federal regulations, Medicaid requirements, and organizational policies.
Requirements:
Bachelor's degree in health administration or a health-related field.
Minimum of 2 years cumulative experience with Medicaid, Managed Care, CMS, and NCQA Health Plan Standards.
Minimum of 2 years experience in Quality Improvement.
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, investigative, and communication skills.
Proficiency with Microsoft Office and audit tracking systems.
Registered Nurse certification preferred.
Licensed Mental Health Professional credentials preferred, including LCSW, LPC, LMFT, BCBA, or equivalent.
Pay Range and Compensation Package:
Base pay range for full-time employment is $73,881.60 to $122,532.80 annually.
Additional compensation may include shift differentials, standby/on-call pay, shift premiums, extra-shift incentives, or bonus opportunities.
Compensation varies based on qualifications, experience, location, market conditions, and business needs.
Benefits & Perks:
Medical, Dental, and Vision insurance plans.
Adoption, Fertility, and Surrogacy reimbursement up to $10,000.
Paid Time Off, Sick Leave, Paid Parental and Family Caregiver Leave.
Emergency Backup Care.
Long-Term, Short-Term Disability, and Critical Illness plans.
Life Insurance.
401(k)/403(b) with Employer Match.
Tuition Assistance up to $5,250 per year and discounted educational opportunities.
Student Debt Pay Down up to $10,000.
Pet Insurance.
Legal Resources Plan.
Opportunity to earn an annual discretionary bonus based on eligibility.
Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.
Note:
RemoteHunter is a recruitment partner of this role. Please note that all employment decisions, including candidate assessment, interviews, hiring, compensation, and employment terms, are made exclusively by the hiring employer.

Work arrangement
Yes