Review and Evaluate Nurse - Med Care Services (169547)

A-Line Staffing is now hiring a “Review and Evaluate Nurse – Med Care Services in Harrisburg, Pennsylvania 17101”, please contact Staffing Manager, Tiona Scroggins @ [email protected]

169547 – Review and Evaluate Nurse – Med Care Services (Intermediate)

Pay: $32.13 per hour

Assignment Details:

• Start Date: May 2026
• End Date: January 2027
• Job Type: Temp to Perm (opportunity to extend or convert to permanent based on business needs)
• Shift: 8:00 AM – 4:00 PM

Work Location:

• Address: 555 Walnut Street, Forum Place, 6th Floor, Harrisburg, PA 17101
• Setting: Central office with field, on-site, and telephonic review responsibilities

Position Overview:
This role involves reviewing and evaluating medical necessity, quality, and compliance of healthcare services provided under the Medical Assistance Program. The nurse will analyze clinical documentation, ensure appropriate care delivery, and identify potential fraud, waste, or abuse , while supporting regulatory compliance and program integrity.

Key Responsibilities:

• Medical Review: Evaluate medical necessity, appropriateness, and quality of care/services
• Documentation Analysis: Review medical records to ensure accurate billing and proper care delivery
• Fraud Detection: Identify and address provider or recipient fraud and abuse
• Clinical Judgment: Apply professional judgment to assess care using clinical guidelines and documentation
• Utilization Review: Conduct prior authorization and post-certification reviews
• Team Leadership: Serve as team lead on multi-staff reviews and coordinate review processes
• Consultation: Provide advisory support to staff and boards to improve procedures
• Representation: Represent the department during appeals and administrative hearings
• Collaboration: Communicate with providers, legal teams, and internal departments

Essential Job Functions:

• Reporting: Prepare detailed reports and professional correspondence
• Regulatory Compliance: Interpret and apply policies, regulations, and standards
• Field Work: Conduct on-site facility visits, desk reviews, and telephonic evaluations
• Travel: Travel statewide, including overnight stays for reviews, meetings, and training
• Communication: Maintain clear verbal and written communication across stakeholders
• Data Entry: Accurately input and manage clinical and review data
• Physical Requirements: Ability to walk long distances, climb stairs, lift equipment, and sit for extended periods
• Legal Support: Testify in administrative/legal hearings and defend decisions
• Confidentiality: Maintain strict confidentiality and professional discretion

Minimum Qualifications:

• Licensure: Current Registered Nurse (RN) license issued by the Pennsylvania State Board of Nursing OR temporary practice permit
• Note: Temporary permit holders must obtain full RN licensure within 1 year
• Experience:
• Minimum 3 years of professional experience in medical assistance, healthcare, or human services

At least 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 and alcohol programs
• Managed care
• Quality management / utilization review
• Related clinical experience
• Technical Skills: Proficiency in Microsoft Office and basic computer systems

Preferred Knowledge & Skills:

• Clinical Tools: Familiarity with InterQual criteria, ICD-9 CM, and current procedural terminology
• Analytical Skills: Ability to identify patterns, discrepancies, and compliance issues
• Decision-Making: Strong clinical judgment and problem-solving abilities
• Attention to Detail: High accuracy in documentation review and reporting
• Interpersonal Skills: Ability to work with cross-functional teams and external providers

Additional Requirements:

• Work Environment: Combination of office-based, remote review, and fieldwork
• Travel Requirement: Frequent statewide travel, including overnight stays
• Independence: Ability to perform tasks independently with occasional expert guidance
• Compliance: Must adhere to all regulatory, legal, and organizational standards

Benefits:
⦁ Benefits are available to full-time employees after 90 days of employment.
⦁ A 401(k) with company match is available after 1 year of service.

INDKS

Pay: $32.13 per hour

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Vision insurance

Application Question(s):

• Do you have at least 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 and alcohol programs
Managed care
Quality management / utilization review
Related clinical experience

• Do you have at least 3 years of professional experience in medical assistance, healthcare, or human services?

Work Location: In person