Registered Nurse (RN) – Expert Medical Examination Consultant (Hybrid)
About The Position
Seeking a Registered Nurse (RN) – Expert Medical Examination Consultant to support program integrity and medical review initiatives in a full-time, long-term contract role based in Harrisburg, PA, with a hybrid schedule (three days remote, two days onsite). This position is responsible for performing detailed clinical and administrative reviews to ensure medical necessity, accuracy of care, and compliance with state and federal healthcare regulations. In this role, the RN will conduct comprehensive medical record reviews, claim evaluations, and clinical assessments related to program integrity and medical examination activities. Responsibilities include evaluating documentation for medical necessity, appropriateness of care, coding accuracy, and regulatory compliance, while identifying potential indicators of fraud, waste, abuse, or quality concerns. The nurse will analyze clinical data, utilization trends, and provider documentation, preparing detailed findings and recommendations to support corrective actions and program oversight. This position involves collaboration with compliance teams, investigators, auditors, and medical directors, as well as participation in case discussions and review activities involving complex clinical scenarios. Additional responsibilities include supporting appeals and follow-up reviews, maintaining strict confidentiality standards, and providing guidance on documentation requirements and medical necessity criteria. The ideal candidate will have strong analytical skills, clinical expertise, and the ability to work independently while managing multiple priorities in a fast-paced, compliance-driven environment.
Requirements
- Registered Nurse (RN) license
- Expert medical examination consultant skills
- Strong analytical skills
- Clinical expertise
- Ability to work independently
- Ability to manage multiple priorities
- Experience in a fast-paced, compliance-driven environment
Responsibilities
- Performing detailed clinical and administrative reviews to ensure medical necessity, accuracy of care, and compliance with state and federal healthcare regulations.
- Conducting comprehensive medical record reviews, claim evaluations, and clinical assessments related to program integrity and medical examination activities.
- Evaluating documentation for medical necessity, appropriateness of care, coding accuracy, and regulatory compliance.
- Identifying potential indicators of fraud, waste, abuse, or quality concerns.
- Analyzing clinical data, utilization trends, and provider documentation.
- Preparing detailed findings and recommendations to support corrective actions and program oversight.
- Collaborating with compliance teams, investigators, auditors, and medical directors.
- Participating in case discussions and review activities involving complex clinical scenarios.
- Supporting appeals and follow-up reviews.
- Maintaining strict confidentiality standards.
- Providing guidance on documentation requirements and medical necessity criteria.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
