City/State
Richmond, VAWork Shift
Multiple shifts availableOverview:
Status: Full-time, permanent position (40 hours)
Standard working hours: 8am to 5pm EST, M-F
Location: Candidate must be located in Central Virginia (Richmond, Fredericksburg, Chesterfield, Petersburg, VA). This position will work remotely 4 days per week and 1 day per week visiting providers in Central Virginia (Richmond, Chesterfield, Petersburg). In-person meetings may be required as needed at Sentara Health Plans (Richmond Office).
Job responsibilities:
As a Clinical Practice Analyst, you will play a key role in ensuring the integrity and effectiveness of clinical services across multiple lines of business. This position is responsible for conducting comprehensive reviews of clinical documentation, evaluating medical necessity, and monitoring provider compliance with regulatory and contractual standards. Analysts may present findings and recommendations to internal committees and leadership, supporting data-driven decisions that improve care delivery and operational performance.
Key Responsibilities:
Conduct detailed reviews of clinical documentation for accuracy, completeness, and compliance with state and federal regulations.
Assess medical necessity, scope, and duration of services against established guidelines.
Identify patterns of outlier activity and escalate concerns for resolution.
Prepare clear, actionable reports and present findings to internal committees or leadership as needed.
Collaborate with providers to implement corrective actions and education initiatives.
Contribute to performance monitoring and reporting to support continuous improvement efforts.
Education:
MLD - Master's Level Degree- REQUIRED
Certification/Licensure:
One of the following is required:
Licensed Clinical Social Worker (LCSW) - State license - North Carolina Social Work Certification and Licensure Board (NCSWCLB)
Licensed Clinical Social Worker (LCSW) - State license - Virginia Department of Health Professionals (VADHP)
Licensed Professional Counselor (LPC) - State license - North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC)
Licensed Professional Counselor (LPC) - State license - Virginia Department of Health Professionals (VADHP)
Registered Nurse (RN) Multi State - Nursing License - North Carolina Board of Nursing (NCBON)
Registered Nurse (RN) Multi State - Nursing License - Virginia Department of Health Professionals (VADHP)
Registered Nurse (RN) Single State - Nursing License - North Carolina Board of Nursing (NCBON)
Registered Nurse (RN) Single State - Nursing License - Virginia Department of Health Professionals (VADHP)
Experience:
At least one (1) year of quality, regulatory, compliance, accreditation, and/or auditing experience REQUIRED
Knowledge of clinical regulatory requirements, experience with CMS and state regulatory and accreditation requirements preferred
Health Plan experience highly preferred
Sentara Health Plans provides health plan coverage to close to one million members in Virginia. We offer a full suite of commercial products including employee-owned and employer-sponsored plans, as well as Individual & Family Health Plans, Employee Assistance Programs and plans serving Medicare and Medicaid enrollees.
Our quality provider network features a robust provider network, including specialists, primary care physicians and hospitals.
We offer programs to support members with chronic illnesses, customized wellness programs, and integrated clinical and behavioral health services—all to help our members improve their health.
Our success is supported by a family-friendly culture that encourages community involvement and creates unlimited opportunities for development and growth.
Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!
To apply, please go to www.sentaracareers.com and use the following as your Keyword Search: JR-93863.
#Indeed
Talroo - Nursing
Healthcare, Managed Care, MCO, Health Plan, Virginia Beach, VA, Virginia, Clinical Practice Analyst, Compliance, Provider, regulatory, care delivery, Central, Richmond, Chesterfield, Petersburg, Licensed Clinical Social Worker, LCSW, Licensed Professional Counselor, LPC, Registered Nurse, RN, Fredericksburg
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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