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.

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 - 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 Pittsburgh, PA, where appropriate workspace, technology, and resources will be provided to support assigned responsibilities.

Benefits

Attractive Compensation plan.Holiday and Vacation program.