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Health Plan Quality Improvement Coordinator

Sentara Health

Virginia Beach, VA(remote)

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JOB DETAILS
SKILLS
Academic Advice, Analysis Skills, Behavioral Health, Centers for Medicare and Medicaid Services (CMS), Clinical Practices/Protocols, Code of Federal Regulations, Communication Skills, Content Management Systems (CMS), Contract Requirements, Corrective Action, Database Report Tools, Dental Insurance, Detail Oriented, Diversity, Documentation, Emergency Care, Employee Orientation, Establish Priorities, External Quality Review Organization (EQRO), Health Plan, Healthcare Quality, Incident Management, Investigative Reports, Leadership, Legal, Licensed Practical Nurse/Licensed Vocational Nurse, Life Insurance, Mail Processing, Maintain Compliance, Medicaid, Organizational Skills, Performance Analysis, Performance Management, Presentation/Verbal Skills, Provider Relations, QoS (Quality of Service), Quality Assurance, Quality Management, Quality Metrics, Quality of Care, Registered Nurse (RN), Regulations, Regulatory Reports, Reimbursement, Root Cause Analysis, Safety/Work Safety, Time Management, Training/Teaching, Trend Analysis, Tuition Fees, Vision Plan, Work From Home
LOCATION
Virginia Beach, VA
POSTED
Today
City/State
Virginia Beach, VA

Work Shift
First (Days)

Overview:

Sentara Health Plans in Virginia Beach is looking to hire a Remote Health Plan Quality Improvement Coordinator.

This is a remote position; however, candidates must reside in Virginia North Carolina or Florida.

The Quality Improvement (QI) Coordinator is responsible for coordinating and conducting Quality Improvement activities related to Critical Incident investigations, Quality of Care (QOC) and Quality of Service (QOS) reviews, and member safety oversight in accordance with Virginia Medicaid (DMAS) requirements, CMS regulations, and Sentara Health Plans (SHP) policies and procedures.

This role supports the Quality Improvement Program by ensuring timely identification, investigation, documentation, analysis, and resolution of Critical Incidents and quality concerns, while promoting continuous quality improvement and optimal care outcomes for SHP members.



Essential Duties and Responsibilities



Critical Incident Management
  • Receives, reviews, and coordinates Critical Incident reports, including but not limited to abuse, neglect, exploitation, sentinel events, mortality reviews, and serious quality of care concerns, in accordance with DMAS and CMS requirements.
  • Ensures timely reporting, investigation, follow-up, and closure of Critical Incidents within required regulatory timeframes.
  • Conducts comprehensive reviews of medicais records, incident reports, and supporting documentation to assess appropriateness of care, services rendered, and member safety outcomes.
  • Identifies trends, root causes, and systemic issues contributing to Critical Incidents and communicates findings to leadership.



Quality of Care and Quality of Service Reviews
  • Coordinates and performs Quality of Care (QOC) and Quality of Service (QOS) investigations, including grievances and referrals from internal and external stakeholders.
  • Applies established clinical and quality standards to determine quality determinations and facilitate corrective actions per the Medical Directors' recommendations, when indicated.
  • Drafts clear, concise investigative summaries, determinations, and correspondence for internal review, regulatory reporting, and provider communication.



Regulatory Compliance and Documentation
  • Ensures compliance with DMAS contract requirements, CMS regulations (including 42 CFR •438), and SHP Quality Program policies.
  • Maintains accurate documentation and case tracking in designated systems (e.g., quality tracking tools, databases, and reports).
  • Prepares data, reports, and supporting documentation for regulatory audits, reviews, and oversight activities, including DMAS, CMS, and external quality review organizations.



Performance Improvement and Reporting
  • Supports Quality Improvement initiatives by contributing to performance monitoring, trend analysis, and targeted improvement activities related to member safety and quality outcomes.
  • Assists with the development and monitoring of Corrective Action Plans (CAPs) and follow-up activities to ensure sustained improvement.
  • Participates in Quality Committees, workgroups, and interdisciplinary meetings as assigned.



Collaboration and Communication
  • Collaborates with internal departments including Care Management, Medical Directors, Behavioral Health, Compliance, and Provider Relations.
  • Coordinates with external stakeholders such as providers, facilities, and community agencies as needed to support investigations and quality improvement efforts.
  • Provides education and guidance to staff and providers related to Critical Incident reporting requirements and quality expectations.


Core Competencies
  • Attention to detail and regulatory accuracy
  • Written and verbal communication
  • Critical thinking and root cause analysis
  • Time management and prioritization
  • Collaboration and professionalism


Education
  • BSN preferred
  • Associate's degree(Required)or
  • LPN Diploma may be accepted in lieu of associate's degree


Certification:
  • Registered Nurse


Experience
  • 3 years of quality improvement experience (Required)
  • 3 years of regulatory and accreditation (Required)


Keywords: Talroo-Allied Health, Quality Improvement, NCQA, MCHIP, DMAS, CMS

Benefits: Caring For Your Family and Your Career

• Medical, Dental, Vision plans

• Adoption, Fertility and Surrogacy Reimbursement up to $10,000

• Paid Time Off and Sick Leave

• Paid Parental & Family Caregiver Leave

• Emergency Backup Care

• Long-Term, Short-Term Disability, and Critical Illness plans

• Life Insurance

• 401k/403B with Employer Match

• Tuition Assistance - $5,250/year and discounted educational opportunities through Guild Education

• Student Debt Pay Down - $10,000

• Reimbursement for certifications and free access to complete CEUs and professional development

•Pet Insurance
•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 30,000-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.

About the Company

S

Sentara Health

Sentara Healthcare employees strive to make our communities healthier places to live, and we're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. Sentara hospitals, programs, and employees are consistently recognized for innovation, clinical achievements, and overall excellence.
COMPANY SIZE
10,000 employees or more
INDUSTRY
Healthcare Services
WEBSITE
https://www.sentara.com/aboutus/careers

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