Remote/Hybrid Registered Nurse (RN) Advocacy & Program ...

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. 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 plusbut 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 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 Medical Assistance Hospice Integrity) Conduct clinical utilization reviews for hospice services under the Medical Assistance (MA) Program by evaluating medical records, terminal diagnoses, prognostic indicators, and plans of care to determine eligibility, medical necessity, appropriateness, and level of care. Apply registered nursing clinical judgment and evidence-based hospice and palliative care standards to ensure MA recipients receive compassionate, appropriate, and high-quality end-of-life care consistent with program requirements and patient goals. Review hospice certifications and recertifications, physician narratives, interdisciplinary team documentation, and supporting clinical evidence to validate terminal prognosis and continued hospice eligibility. Assess hospice provider billing, claims, and documentation to ensure compliance with MA hospice regulations and identify potential fraud, waste, or abuse related to levels of care, service intensity, or length of stay. Review documentation submitted through electronic provider portals, fax, telephone communications, and U.S. mail to support timely and accurate hospice utilization determinations. Make authorization determinations within RN scope of practice by approving, modifying, or denying hospice service requests, or referring cases to physician advisors when prognosis, level of care (routine home care, continuous care, inpatient respite, or general inpatient), or medical necessity is unclear. Collaborate with physician/medical consultants to support peer-to-peer discussions with hospice medical directors and certifying physicians regarding prognosis, symptom management, and appropriate hospice level of care. Accurately document clinical findings, utilization review decisions, and rationale in electronic systems, generating authorization notifications, denial letters, reason codes, and appeal rights in accordance with MA regulations. Conduct re-evaluations of previously denied or modified hospice services upon request by hospice providers or facilities, in collaboration with physician/medical consultants as appropriate. Review hospice-related appeals by analyzing medical records, preparing case summaries and exhibits, and providing testimony at administrative hearings using knowledge of MA hospice regulations, utilization review principles, and appeal procedures. Interpret MA hospice policies, regulations, and utilization management guidelines for internal staff, hospice providers, and stakeholders through consultation, meetings, and educational outreach. Participate in interdisciplinary collaboration with hospice providers, medical consultants, legal staff, and program leadership to support consistent, defensible, and patient-centered utilization determinations. Maintain professional competence through continuing education, hospice-specific training, and review of current palliative care literature to remain current with evolving standards of end-of-life care and regulatory requirements. Provide cross-coverage in other MA program areas as needed, maintaining working knowledge through training and updates to support continuity of operations. Respond to inquiries and correspondence from recipients, hospice providers, legislators, legal offices, and external agencies to explain hospice coverage criteria, utilization decisions, and administrative processes. Maintain complete and accurate records in compliance with MA hospice 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 duties. Attractive Compensation plan. Holiday and Vacation program.

Created: 2026-03-04