Registered Nurse (RN) – Pharmacy/Ambulance/ SBAP Services Review
About The Position
The Registered Nurse (RN) supports program integrity and medical review initiatives in a full-time, long-term contract role based in Harrisburg, Pennsylvania, with a hybrid schedule of three days remote and two days onsite. The position conducts retrospective medical record and claims reviews of Medical Assistance providers to identify potential fraud, abuse, billing discrepancies, and violations of state and federal regulations. The RN performs detailed clinical and administrative reviews, including claim evaluations and clinical assessments related to program integrity and medical examination activities. The role evaluates documentation for medical necessity, appropriateness of care, coding accuracy, and regulatory compliance, and identifies potential fraud, waste, abuse, or quality concerns. The RN analyzes clinical data, utilization trends, and provider documentation, then prepares findings and recommendations to support corrective actions and program oversight. The position collaborates with compliance teams, investigators, auditors, and medical directors; participates in case discussions and reviews involving complex clinical scenarios; and supports appeals and follow-up reviews. It also involves maintaining strict confidentiality and providing guidance on documentation requirements and medical necessity criteria. The role requires strong clinical and analytical skills, independent work, and the ability to manage multiple priorities in a fast-paced, compliance-driven environment.
Requirements
- Active Registered Nurse (RN) license.
- Knowledge of medical necessity, quality of care, and healthcare compliance.
- Ability to identify billing discrepancies and potential fraud or abuse.
- Strong analytical, organizational, written communication, and clinical skills.
- Proficiency in Microsoft Office, including Word and Excel.
- Ability to prepare reports, case summaries, and professional correspondence.
- Ability to participate in provider meetings, teleconferences, and potential hearings.
- Ability to research and interpret state and federal healthcare regulations.
- Ability to work independently and manage multiple priorities in a fast-paced, compliance-driven environment.
Nice To Haves
- Experience with medical record reviews, claims analysis, and healthcare documentation.
Responsibilities
- Conduct retrospective medical record and claims reviews of Medical Assistance providers.
- Evaluate documentation for medical necessity, appropriateness of care, coding accuracy, and regulatory compliance.
- Identify potential fraud, waste, abuse, billing discrepancies, violations of regulations, and quality concerns.
- Analyze clinical data, utilization trends, claims, and provider documentation.
- Prepare detailed findings, recommendations, reports, case summaries, and professional correspondence to support corrective actions and program oversight.
- Collaborate with compliance teams, investigators, auditors, and medical directors.
- Participate in case discussions, complex clinical reviews, provider meetings, teleconferences, and potential hearings.
- Support appeals and follow-up reviews.
- Maintain strict confidentiality standards.
- Provide guidance on documentation requirements and medical necessity criteria.
- Research and interpret state and federal healthcare regulations.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
