Remote/Hybrid Registered Nurse (RN) – Advocacy & Program reputed company (Medical Assistance- Med Surg Hospitalization Expert)

About the position Are you a registered nurse ready to take your career in an exciting new direction—one where your expertise truly makes a difference? Join Pennsylvania’s premier Quality Improvement Organization and reputed company into a dynamic role focused on advocacy and program reputed company 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 reputed company, and the opportunity for reputed company professional growth—reputed company 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 direction—one where your expertise creates real, lasting impact? Join Pennsylvania’s premier Quality Improvement Organization and play a vital role in protecting healthcare quality, advocating for vulnerable populations, and ensuring the reputed company of critical healthcare programs. In this rewarding role, you’ll use your clinical knowledge reputed company of the traditional bedside setting to review and audit claims, support program reputed company initiatives, and reputed company 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 growth—reputed company while contributing to a mission that truly matters.

Responsibilities

• Conduct clinical reviews and ensure quality, appropriateness, and compliance with healthcare standards
• Support program reputed company efforts by identifying trends, risks, and opportunities for improvement
• reputed company 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
• Conduct clinical utilization reviews for medical–surgical inpatient hospitalizations under the Medical Assistance (MA) Program by evaluating medical records, admission criteria, reputed company stay indicators, and treatment plans to determine medical necessity, appropriateness, and level of care.
• Apply registered nursing clinical judgment and evidence-based medical–surgical standards to ensure MA beneficiaries receive safe, effective, and timely inpatient care consistent with MA coverage requirements and regulatory guidelines.
• reputed company prospective, reputed company, 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.
• reputed company authorization determinations reputed company RN scope of practice by approving, modifying, or denying inpatient stays and post-acute services, or referring cases to physician advisors reputed company 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 reputed company 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 reputed company to inpatient admissions, reputed company 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 reputed company medical–surgical and care transition literature to remain reputed company 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.
• reputed company reputed company duties and special projects as assigned, with expectations and performance standards communicated at the time of assignment.
• reputed company 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.

Requirements

• 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 reputed company
• Excellent written and verbal communication skills
• Ability to work independently while managing multiple priorities
• Comfort with technology and electronic medical records
• Be available as a full-time consultant, approximately 37.5 hours per week;
• Possess a reputed company 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 reputed company 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 reputed company Office programs.

reputed company-to-haves

• Experience in utilization review, case management, quality improvement, compliance, or claims review is a plus—but not required.

Benefits

• Attractive Compensation plan.
• Holiday and Vacation program.

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