Performance Measurement Specialist III
Performance Measurement Specialist III
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$ 46508 - 77500
1 Vacancy
Job Description
City/State
Virginia Beach VAWork Shift
First (Days)Overview:
Sentara Health is looking for an Performance Measurement Specialist III/ Appeals & Grievances Auditor to join our team
The A&G Auditor is responsible for reviewing and evaluating the accuracy timeliness and regulatory compliance of appeals and grievances processing. This includes monitoring case handling against CMS state Medicaid and NCQA standards identifying trends and recommending corrective actions to ensure continuous improvement and compliance.
Key Responsibilities:
Conduct retrospective audits of appeals and grievances cases to assess compliance with regulatory accreditation and internal standards (e.g. CMS DMAS NCQA state BOI).
Validate proper categorization case resolution notification language and timeliness.
Identify trends root causes and opportunities for process improvement or staff coaching.
Collaborate with Compliance Legal and Operational leaders to support corrective action plans and regulatory readiness.
Participate in mock audits and support external audit preparedness (CMS Program Audits state reviews etc.).
Document audit findings in audit tracking tools and produce clear actionable summaries.
Provide feedback and coaching to case processors when applicable.
Education:
HS - High School Grad or Equivalent
Certification/Licensure
No specific certification or licensure requirements
Experience Requirements
Required Qualifications:
2 years of experience in healthcare appeals and grievances or regulatory quality auditing.
Strong understanding of CMS Medicare regulations Medicaid requirements and NCQA standards.
Working knowledge of regulatory timelines (e.g. 24/72-hour expedited timeframes 30-day standard etc.).
Experience with case management systems (e.g. Salesforce JIVA QNXT ).
Strong analytical skills attention to detail and ability to interpret complex regulations.
Proficient in Microsoft Office Suite (especially Excel and Word).
Preferred Qualifications:
Experience supporting or participating in CMS Program Audits or state-level reviews.
Familiarity with DMAS (Virginia Medicaid) regulations if applicable.
Previous experience creating or refining audit tools/checklists.
Experience delivering feedback or training to operational staff.
Quality certification (e.g. CHC CPQA) a plus.
We provide market-competitive compensation packages inclusive of base pay incentives and benefits. The base pay rate for Full Time employment is:$46508.80-$77500.80. Additional compensation may be available for this role such as shift differentials standby/on-call overtime premiums extra shift incentives or bonus opportunities.
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.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
