Are you a registered nurse ready to take your career in an exciting new directionone where your expertise truly makes a difference Join Pennsylvanias premier Quality Improvement Organization and step into a dynamic role focused on advocacy and program integrity through compliance management. Here youll champion the needs of vulnerable populations safeguard the quality of care and influence healthcare outcomes on a meaningful scale. Enjoy the freedom of working from home the flexibility and autonomy to manage your workday and the opportunity for continuous professional growthall while being part of a passionate mission-driven team dedicated to improving healthcare across the Commonwealth.
Are you a registered nurse ready to take your career in an exciting new directionone where your expertise creates real lasting impact Join Pennsylvanias premier Quality Improvement Organization and play a vital role in protecting healthcare quality advocating for vulnerable populations and ensuring the integrity of critical healthcare programs.
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
Be available as a full-time consultant approximately 37.5 hours per week;
Possess a current license to practice as a Registered Nurse issued by the Pennsylvania
State Board of Nursing; or possess a non-renewable temporary practice permit issued
by the Pennsylvania State Board of Nursing. Resources possessing non-renewable
temporary practice permits must obtain licensing as a Registered Nurse within the
one-year period as defined by the Pennsylvania State Board of Nursing;
Possess a documented work history of three (3) or more years of professional
experience with medical assistance health care services or human services or any
equivalent combination of experience and training;
Possess basic computer skills including familiarity with Microsoft Office programs.
Evaluate and review medical physical rehabilitative restorative and other care being provided to determine appropriateness.
Review understand and relate pertinent Departmental State and Federal policies licensing requirements and regulations to ensure compliance by Medical Assistance (MA)/OLTL providers.
Participate in the development of new and/or revision to existing medical assistance policies and regulations.
Coordinate and interact with other Agencies and Departments to ensure appropriate services for individuals using long term living services.
Perform monitoring reviews in all Long-Term Living settings to determine that the provision and adequacy of medical social physical rehabilitative and restorative care services are being provided in accordance to all regulations and licensing criteria.
Review Minimum Data Set (MDS) submitted to the MDS database for accuracy and documentation support in the clinical records.
Review PA Pre-Admission Screening Resident Review (PA-PASRR-ID) process to assure nursing facilities (NF) compliance with the Omnibus Budget Reconciliation Act (OBRA).
Perform evaluations of identified targeted individuals residing in long term care facilities including submission of packet with recommendations to the appropriate Program Office (OMHSAS ODP ORC or DMVA) for review.
Monitor appropriateness of NF admissions and determine need for continued stay by reviewing clinical records evaluate discharge plans and interview staff and residents.
Perform financial reviews to identify recoveries to ensure adjustments are made for any inappropriate payments or billings in accordance with established regulations and guidelines.
Benefits
Attractive Compensation plan. Holiday and Vacation program.
Required Skills:
Current Pennsylvania State Board of Nursing license
Required Education:
Bachelors degree in a Health or Human services related course of study. Examples but not limited to: Nursing Social work Psychology Occupational Therapist Physical Therapist Physician Emergency Medical Technician (EMT) OR Associates Degree in a Health or Human Services related course of study AND 2 years experience working in that field of study OR A minimum of one year experience in a health or human services related field demonstrating an ability to perform the description
Are you a registered nurse ready to take your career in an exciting new directionone where your expertise truly makes a difference Join Pennsylvanias premier Quality Improvement Organization and step into a dynamic role focused on advocacy and program integrity through compliance management. Here yo...
Are you a registered nurse ready to take your career in an exciting new directionone where your expertise truly makes a difference Join Pennsylvanias premier Quality Improvement Organization and step into a dynamic role focused on advocacy and program integrity through compliance management. Here youll champion the needs of vulnerable populations safeguard the quality of care and influence healthcare outcomes on a meaningful scale. Enjoy the freedom of working from home the flexibility and autonomy to manage your workday and the opportunity for continuous professional growthall while being part of a passionate mission-driven team dedicated to improving healthcare across the Commonwealth.
Are you a registered nurse ready to take your career in an exciting new directionone where your expertise creates real lasting impact Join Pennsylvanias premier Quality Improvement Organization and play a vital role in protecting healthcare quality advocating for vulnerable populations and ensuring the integrity of critical healthcare programs.
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
Be available as a full-time consultant approximately 37.5 hours per week;
Possess a current license to practice as a Registered Nurse issued by the Pennsylvania
State Board of Nursing; or possess a non-renewable temporary practice permit issued
by the Pennsylvania State Board of Nursing. Resources possessing non-renewable
temporary practice permits must obtain licensing as a Registered Nurse within the
one-year period as defined by the Pennsylvania State Board of Nursing;
Possess a documented work history of three (3) or more years of professional
experience with medical assistance health care services or human services or any
equivalent combination of experience and training;
Possess basic computer skills including familiarity with Microsoft Office programs.
Evaluate and review medical physical rehabilitative restorative and other care being provided to determine appropriateness.
Review understand and relate pertinent Departmental State and Federal policies licensing requirements and regulations to ensure compliance by Medical Assistance (MA)/OLTL providers.
Participate in the development of new and/or revision to existing medical assistance policies and regulations.
Coordinate and interact with other Agencies and Departments to ensure appropriate services for individuals using long term living services.
Perform monitoring reviews in all Long-Term Living settings to determine that the provision and adequacy of medical social physical rehabilitative and restorative care services are being provided in accordance to all regulations and licensing criteria.
Review Minimum Data Set (MDS) submitted to the MDS database for accuracy and documentation support in the clinical records.
Review PA Pre-Admission Screening Resident Review (PA-PASRR-ID) process to assure nursing facilities (NF) compliance with the Omnibus Budget Reconciliation Act (OBRA).
Perform evaluations of identified targeted individuals residing in long term care facilities including submission of packet with recommendations to the appropriate Program Office (OMHSAS ODP ORC or DMVA) for review.
Monitor appropriateness of NF admissions and determine need for continued stay by reviewing clinical records evaluate discharge plans and interview staff and residents.
Perform financial reviews to identify recoveries to ensure adjustments are made for any inappropriate payments or billings in accordance with established regulations and guidelines.
Benefits
Attractive Compensation plan. Holiday and Vacation program.
Required Skills:
Current Pennsylvania State Board of Nursing license
Required Education:
Bachelors degree in a Health or Human services related course of study. Examples but not limited to: Nursing Social work Psychology Occupational Therapist Physical Therapist Physician Emergency Medical Technician (EMT) OR Associates Degree in a Health or Human Services related course of study AND 2 years experience working in that field of study OR A minimum of one year experience in a health or human services related field demonstrating an ability to perform the description
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