RemoteHybrid Registered Nurse (RN) – Advocacy & Program Integrity (Medical Assistance 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 Utilization Review / Program Integrity)

• Conduct clinical utilization reviews by evaluating medical records treatment plans and supporting documentation to determine medical necessity appropriateness quality and level of care in accordance with Medical Assistance (MA) program requirements.
  

• Apply nursing judgment and evidence-based clinical standards to ensure MA recipients receive safe appropriate and high-quality care while supporting program integrity and regulatory compliance.
  

• Assess provider billing and documentation to verify compliance with MA policies and identify potential fraud waste or abuse.
  

• Review clinical documentation submitted through electronic provider portals telephone communications fax and U.S. mail ensuring completeness and accuracy for utilization determinations.
  

• Make authorization determinations by approving modifying or denying service requests within RN scope of practice or refer cases to physician advisors for secondary medical review when medical necessity or level of care is unclear.
  

• Collaborate with physician/medical consultants to support peer-to-peer reviews and facilitate discussions with ordering providers regarding clinical justification appropriate care settings and service coverage.
  

• Accurately document utilization review decisions and clinical rationale in electronic systems generating authorization notices denial letters reason codes and appeal rights in compliance with regulatory standards.
  

• Participate in retrospective concurrent and prospective utilization reviews including re-evaluations of previously denied services upon request by providers or facilities.
  

• Review and prepare appeal cases by analyzing medical records developing exhibits and correspondence and providing testimony at administrative hearings using knowledge of MA regulations utilization management principles and appeal processes.
  

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

• Engage in interdisciplinary collaboration with internal departments medical consultants legal staff and external stakeholders to support consistent and defensible utilization determinations.
  

• Maintain ongoing professional development through continuing education conferences and review of current medical literature to remain current with standards of care clinical guidelines and utilization review best practices.
  

• Provide cross-coverage in other program areas as needed maintaining competency through training and updates to ensure continuity of program operations.
  

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

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

• Perform related duties and special projects as assigned with expectations and performance standards communicated for each assignment.
  

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

Benefits