Job Description

Registered Nurse: Review and Evaluation

Are you a registered nurse ready to take your career in an exciting new directionone where your expertise truly makes a difference? Join Pennsylvania's premier Quality Improvement Organization and step into a dynamic role focused on advocacy and program integrity through compliance management. Here, you'll 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.

In this rewarding role, you'll 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. You'll 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.

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.

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.

Mission-driven work with Pennsylvania's 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 you're 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.

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.

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.

Attractive Compensation plan. Holiday and Vacation program.

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