RemoteHybrid Registered Nurse (RN) – Advocacy & Program Integrity (Medical Assistance- Med Surg Hospitalization Expert)

In this rewarding role youll use your clinical knowledge outside of the traditional bedside setting to review and audit claims support program integrity initiatives and advocate for beneficiaries across the Commonwealth. Youll enjoy the flexibility of working from home the autonomy to manage your work and meaningful opportunities for professional growthall while contributing to a mission that truly matters.

What Youll Do

• Conduct clinical reviews and ensure quality appropriateness and compliance with healthcare standards
  

• Support program integrity efforts by identifying trends risks and opportunities for improvement
  

• Advocate for beneficiaries with a strong focus on protecting and improving care for vulnerable populations
  

• Apply nursing judgment to analyze medical records documentation and billing data
  

• Collaborate with interdisciplinary teams providers and stakeholders to promote best practices
  

• Contribute to quality improvement initiatives that strengthen healthcare delivery across Pennsylvania
  

What Were Looking For

• Active unrestricted Registered Nurse (RN) license
  

• Strong clinical background with the ability to apply nursing judgment analytically
  

• Interest in advocacy quality improvement and healthcare program integrity
  

• Excellent written and verbal communication skills
  

• Ability to work independently while managing multiple priorities
  

• Comfort with technology and electronic medical records
  

Experience in utilization review case management quality improvement compliance or claims review is a plusbut not required.

Why Join Us

• Mission-driven work with Pennsylvanias leading Quality Improvement Organization
  

• Make a real impact on healthcare quality and outcomes for vulnerable populations
  

• Remote work enjoy the convenience and balance of working from home
  

• Autonomy and flexibility in how you manage your workday
  

• Advocacy-focused role that values your nursing voice and expertise
  

• Career development opportunities to grow beyond traditional nursing roles
  

• Supportive collaborative team culture committed to excellence and integrity
  

If youre a registered nurse seeking purpose-driven work professional growth and the flexibility to balance your life and careerthis is your opportunity. Apply today and help shape the future of healthcare quality in Pennsylvania.

Requirements

Principal Duties and Responsibilities (RN Medical Assistance Inpatient Utilization Review & Discharge Planning)

• Conduct clinical utilization reviews for medicalsurgical inpatient hospitalizations under the Medical Assistance (MA) Program by evaluating medical records admission criteria continued stay indicators and treatment plans to determine medical necessity appropriateness and level of care.
  

• Apply registered nursing clinical judgment and evidence-based medicalsurgical standards to ensure MA beneficiaries receive safe effective and timely inpatient care consistent with MA coverage requirements and regulatory guidelines.
  

• Perform prospective concurrent and retrospective reviews of inpatient admissions to assess appropriate level of care (e.g. inpatient vs. observation) length of stay and readiness for discharge.
  

• Evaluate discharge planning documentation to ensure timely safe and effective transitions of care including coordination of post-acute services such as home health durable medical equipment (DME) skilled nursing facility (SNF) rehabilitation behavioral health follow-up and community-based supports.
  

• Assess provider documentation and hospital billing to ensure compliance with MA policies inpatient reimbursement rules and discharge planning requirements and identify potential fraud waste or abuse.
  

• Review clinical documentation submitted through electronic medical records provider portals telephone communications fax and U.S. mail to support utilization and discharge determinations.
  

• Make authorization determinations within RN scope of practice by approving modifying or denying inpatient stays and post-acute services or referring cases to physician advisors when medical necessity level of care or discharge disposition is unclear.
  

• Collaborate with physician/medical consultants and hospital care teams to support peer-to-peer discussions regarding continued stay criteria discharge readiness and appropriate post-discharge level of care.
  

• Document utilization review findings clinical rationale and discharge planning decisions in electronic systems generating authorization notifications denial letters reason codes and appeal information in compliance with MA regulations.
  

• Conduct re-reviews and reconsiderations of inpatient and post-acute service decisions upon request by hospitals providers or facilities in collaboration with physician/medical consultants as needed.
  

• Review and prepare appeal cases related to inpatient admissions continued stays and discharge determinations by analyzing medical records preparing case summaries and exhibits and providing testimony at administrative hearings using knowledge of MA regulations and appeal procedures.
  

• Interpret MA inpatient and discharge planning policies regulations and utilization management guidelines for hospital staff providers and internal stakeholders through consultation education and meetings.
  

• Participate in interdisciplinary collaboration with hospitals post-acute providers medical consultants social services legal staff and program leadership to support patient-centered compliant and efficient transitions of care.
  

• Maintain professional competence through continuing education and review of current medicalsurgical and care transition literature to remain current with standards of care utilization review best practices and regulatory changes.
  

• Provide cross-coverage in other MA program areas as needed maintaining working knowledge through training and updates to support continuity of program operations.
  

• Respond to inquiries and correspondence from beneficiaries providers legislators legal offices and external agencies to explain inpatient coverage decisions discharge planning requirements and administrative processes.
  

• Maintain accurate case documentation and records in accordance with MA regulations accreditation standards and organizational policies.
  

• Perform related duties and special projects as assigned with expectations and performance standards communicated at the time of assignment.
  

• When required work at Department-designated locations. The primary work location is Harrisburg PA where appropriate workspace technology and resources will be provided to support assigned responsibilities.
  

Benefits