Performance Measurement Specialist III

City/State

Work Shift

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.

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.

HS - High School Grad or Equivalent

No specific certification or licensure 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.

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.