Offer summary

Qualifications:

High school diploma or equivalent is required., Minimum of 2 years of experience in Claims Processing, Customer Service, Enrollment, or System Administration., Strong knowledge of Appeals and Grievances operations and compliance standards., Experience conducting audits and analyzing process and compliance risks..

Key responsibilities:

Conduct random and focused audits across operational areas, especially Appeals and Grievances.

Assess company operations, compliance, and process risks, and present findings to management.

Support strategic initiatives to enhance audits, internal controls, and policies.

Assist with external audits from agencies like CMS and DMAS.

Job description

City/State

Virginia Beach, VA

Work Shift

First (Days)

Overview:

The Performance Measurement Specialist III is responsible for executing both random and focused audits across various operational areas, with a strong emphasis on Appeals and Grievances. This role assesses company operations, compliance, and process risks, and presents detailed audit findings and actionable recommendations to management and stakeholders.

The specialist supports strategic initiatives to enhance the audit function, improve internal controls, and refine operational and management policies and procedures. This role also plays a key part in supporting external audits, including those from CMS, DMAS, and group clients. Ideal candidates will bring a solid background in claims operations along with deep expertise in Appeals and Grievances processes.

Education

HS - High School Grad or Equivalent

Certification/Licensure

No specific certification or licensure requirements

Experience Requirements

Minimum 2 years of experience in Claims Processing, Customer Service, Enrollment, or System Administration
Strong working knowledge of Appeals and Grievances operations and compliance standards
Experience conducting audits and analyzing process and compliance risks
Ability to prepare and present detailed audit reports with strategic recommendations
Familiarity with supporting external audits (CMS, DMAS, or similar regulatory bodies)

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 if established 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.

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