Registered Nurse (RN) - Prior Authorization & Program Exception Review (Hybrid)
We are seeking a Registered Nurse (RN) – Medical Necessity Review (Prior Authorization / Program Exception) to support the Pennsylvania Medical Assistance (Medicaid) program in a full-time, long-term contract role based in Harrisburg, PA, with a hybrid schedule (three days remote, two days onsite). This position focuses on reviewing outpatient authorization requests and program exception cases to ensure services are medically necessary, appropriately delivered, and compliant with state and federal regulations.
In this role, the nurse will review outpatient service authorization requests, including Prior Authorization and 1150 Waiver (Program Exception) requests for services such as medical supplies, prosthetics, orthotics, durable medical equipment (DME), skilled nursing care, home health services, and emergency medical services. The RN will evaluate clinical documentation to determine whether requested items and services meet Medical Assistance requirements for necessity.
The position also involves assessing requests that exceed standard fee schedules or quantity limits and coordinating with Rate Setting when additional pricing review is required. The nurse will ensure that appropriate fees are applied and that all determinations align with program guidelines while meeting established productivity standards.
This role requires strong analytical skills, attention to detail, and the ability to interpret medical records and regulatory requirements. The RN will work both independently and collaboratively to ensure accurate determinations, support program integrity, and maintain compliance across all authorization and exception review processes.
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