Performance Measurement Specialist III

City/State

Work Shift

Overview:

Sentara Health is looking for an Performance Measurement Specialist III/ Appeals & Grievances Auditor to join our team

The A&G Auditor is responsible for reviewing and evaluating the accuracy, timeliness, and regulatory compliance of appeals and grievances processing. This includes monitoring case handling against CMS, state Medicaid, and NCQA standards, identifying trends, and recommending corrective actions to ensure continuous improvement and compliance.

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.

We provide market-competitive compensation packages, inclusive of base pay, incentives, and benefits. The base pay rate for Full Time employment is:$46,508.80-$77,500.80. Additional compensation may be available for this role such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

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.