Review & Evaluation Nurse (Hybrid)-{169547}

Review & Evaluation Nurse (Hybrid)-{169547}

Location: Harrisburg, PA 17101
Pay: $32.00/hour
Schedule: Monday-Friday, 8:00am-4:00pm (2 days onsite, 3 days WFH)

· Training may be onsite!

· Some travel may be required, and additional details can be discussed further during interviews

Overview

We are hiring an R&E Nurse to support medical review activities connected to Pennsylvania’s Medical Assistance program. This is an onsite role focused on reviewing records, applying regulations/criteria, and making professional nursing judgments regarding medical necessity and appropriateness of services.

Key Responsibilities

• Review and evaluate medical necessity, appropriateness, quality, and adequacy of care/services billed under Medical Assistance
• Examine medical records & documentation to confirm services align with requirements
• Identify potential fraud, waste, or abuse concerns & support corrective actions
• Analyze documentation submitted by providers (including system-submitted documentation) and make professional clinical determinations
• Conduct reviews in the central office, onsite at facilities, and/or by phone (depending on the service type)
• Prepare written correspondence and reports and maintain accurate documentation
• Provide consultative support to improve service delivery and administrative procedures

Required Skills & Qualifications

• Active RN license issued by the Pennsylvania State Board of Nursing
• 3+ years professional experience in medical assistance, healthcare, or human services
• 3+ years of recent experience (within the last 5 years) in one or more of the following:
• • Long-term care, acute care, behavioral health, drug & alcohol, managed care, quality management/utilization review, or similar clinical experience

Keywords

RN, Registered Nurse, Utilization Review, Medical Review, Quality Management, Managed Care, Long-Term Care, Acute Care, Behavioral Health, Documentation Review, Medical Assistance, Compliance, Prior Authorization, Post-Certification Review