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Remote/Hybrid Registered Nurse (RN) - Advocacy & Program Integrity (Medical Assistance- Med Surg Hos

Job Description
Are you a registered nurse ready to take your career in an exciting newdirection-one where your expertise truly makes a difference? JoinPennsylvania's premier Quality Improvement Organization and step into adynamic 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 ameaningful scale. Enjoy the freedom of working from home, theflexibility and autonomy to manage your workday, and the opportunity forcontinuous professional growth-all while being part of a passionate,mission-driven team dedicated to improving healthcare across theCommonwealth.

Are you a registered nurse ready to take your career in an excitingnew 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 forvulnerable populations, and ensuring the integrity of criticalhealthcare programs.

In this rewarding role, you'll use your clinical knowledge outside ofthe traditional bedside setting to review and audit claims, supportprogram integrity initiatives, and advocate for beneficiaries across theCommonwealth. You'll enjoy the flexibility of working from home, theautonomy to manage your work, and meaningful opportunities forprofessional growth-all while contributing to a mission that trulymatters.

What You'll 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 We're 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 plus-but not required.

Why Join Us

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 andcareer-this 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.

Principal Duties and Responsibilities (RN - Medical Assistance Inpatient Utilization Review & Discharge Planning)

Conduct clinical utilization reviews for medical-surgical inpatient hospitalizations under the Medical Assistance (MA) Program by evaluating medical records, admission criteria, continued 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.
Perform prospective, concurrent, 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.
Make authorization determinations within RN scope of practice by approving, modifying, or denying inpatient stays and post-acute services, or referring cases to physician advisors when 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 continued 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 related to inpatient admissions, continued 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 current medical-surgical and care transition literature to remain current 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.
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 responsibilities.