Quality Improvement Specialist

City/State

Work Shift

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.

• 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.

• Bachelor's degree in health administration or health-related field (required)

• Registered Nurse (preferred)

• 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

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.

• 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