RemoteHybrid Registered Nurse (RN) – Advocacy & Program Integrity (Hospice 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 Hospice Integrity)

• Conduct clinical utilization reviews for hospice services under the Medical Assistance (MA) Program by evaluating medical records terminal diagnoses prognostic indicators and plans of care to determine eligibility medical necessity appropriateness and level of care.
  

• Apply registered nursing clinical judgment and evidence-based hospice and palliative care standards to ensure MA recipients receive compassionate appropriate and high-quality end-of-life care consistent with program requirements and patient goals.
  

• Review hospice certifications and recertifications physician narratives interdisciplinary team documentation and supporting clinical evidence to validate terminal prognosis and continued hospice eligibility.
  

• Assess hospice provider billing claims and documentation to ensure compliance with MA hospice regulations and identify potential fraud waste or abuse related to levels of care service intensity or length of stay.
  

• Review documentation submitted through electronic provider portals fax telephone communications and U.S. mail to support timely and accurate hospice utilization determinations.
  

• Make authorization determinations within RN scope of practice by approving modifying or denying hospice service requests or referring cases to physician advisors when prognosis level of care (routine home care continuous care inpatient respite or general inpatient) or medical necessity is unclear.
  

• Collaborate with physician/medical consultants to support peer-to-peer discussions with hospice medical directors and certifying physicians regarding prognosis symptom management and appropriate hospice level of care.
  

• Accurately document clinical findings utilization review decisions and rationale in electronic systems generating authorization notifications denial letters reason codes and appeal rights in accordance with MA regulations.
  

• Conduct re-evaluations of previously denied or modified hospice services upon request by hospice providers or facilities in collaboration with physician/medical consultants as appropriate.
  

• Review hospice-related appeals by analyzing medical records preparing case summaries and exhibits and providing testimony at administrative hearings using knowledge of MA hospice regulations utilization review principles and appeal procedures.
  

• Interpret MA hospice policies regulations and utilization management guidelines for internal staff hospice providers and stakeholders through consultation meetings and educational outreach.
  

• Participate in interdisciplinary collaboration with hospice providers medical consultants legal staff and program leadership to support consistent defensible and patient-centered utilization determinations.
  

• Maintain professional competence through continuing education hospice-specific training and review of current palliative care literature to remain current with evolving standards of end-of-life care and regulatory requirements.
  

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

• Respond to inquiries and correspondence from recipients hospice providers legislators legal offices and external agencies to explain hospice coverage criteria utilization decisions and administrative processes.
  

• Maintain complete and accurate records in compliance with MA hospice 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 duties.
  

Benefits