Remote/Hybrid Registered Nurse (RN) – Advocacy & Program Integrity (Medical Assistance Expert)

The CKHobbie Group•Pittsburgh, PA

175d•Hybrid

About The Position

This role is for a Registered Nurse (RN) focused on advocacy and program integrity through compliance management. The position involves reviewing and auditing claims, supporting program integrity initiatives, and advocating for beneficiaries. The role offers the flexibility of working from home, autonomy in managing the workday, and opportunities for professional growth within Pennsylvania's leading Quality Improvement Organization. The nurse will use clinical knowledge outside of a traditional bedside setting to influence healthcare outcomes and safeguard the quality of care for vulnerable populations.

Requirements

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.
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.

Nice To Haves

Experience in utilization review, case management, quality improvement, compliance, or claims review is a plus—but not required.

Responsibilities

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.
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.