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Award-winning: Sentara is a Virginia and Northeastern North Carolina based not-for-profit integrated healthcare provider that has been in business for over 131 years. Offering more than 500 sites of care including 12 hospitals, PACE (Elder Care), home health, hospice, medical groups, imaging services, therapy, outpatient surgery centers, and an 858,000 member health plan. The people of the communities that we serve have nominated Sentara “Employer of Choice” for over ten years. U.S. News and World Report has recognized Sentara as having the Best Hospitals for 15+ years. Sentara offers professional development and a continued employment philosophy!
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.
Education:
HS – High School Grad or Equivalent
Certification/Licensure
No specific certification or licensure requirements
Experience Requirements
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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).
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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 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.