Travel Nurse RN - Quality Assurance
Harrisburg, PA
GLC On-The-Go
5x8 hrs, Days

Review and Evaluation Registered Nurse - Harrisburg, PA

Seeking a dedicated and detail-oriented Review & Evaluation (R&E) Nurse. This role focuses on ensuring the quality, appropriateness, and compliance of medical services provided under the Medical Assistance Program.

Key Responsibilities

• Review and evaluate medical records and documentation to determine medical necessity, quality, and appropriateness of care
• Analyze provider submissions and PROMISe™ data to ensure compliance with Medical Assistance regulations
• Identify potential fraud, abuse, or improper billing and recommend corrective actions
• Conduct on-site, desk, and telephonic reviews of service providers
• Communicate findings with providers, staff, and stakeholders, including advisory boards and legal representatives
• Prepare detailed reports, correspondence, and documentation of findings
• Provide consultative support to improve service delivery and administrative procedures
• Serve as a team leader on complex reviews when required
• Represent the Department in administrative or legal hearings as needed

Minimum Qualifications

• Current Registered Nurse (RN) license issued by the Pennsylvania State Board of Nursing

OR

• Non-renewable temporary practice permit (must obtain RN licensure within one year)
• Three (3) years of professional experience in medical assistance (MA), healthcare services, or human services
• At least three (3) years of recent (within the last five years) experience in one or more of the following:
  • Long-term care
  • Acute care
  • Behavioral health
  • Drug and alcohol services
  • Managed care
  • Quality management/utilization review
  • Other related clinical settings
• Proficiency in writing and basic computer skills, including Microsoft Office
• Knowledge of InterQual criteria, ICD-9 CM, and CPT terminology (preferred)
• Ability to exercise professional judgment in identifying irregular patterns and determining appropriate actions

Essential Skills & Abilities

• Strong analytical and critical thinking skills
• Ability to interpret and apply healthcare regulations, policies, and standards
• Effective verbal and written communication skills
• Ability to establish and maintain professional working relationships
• Capability to conduct fieldwork, including travel across the state (overnight stays may be required)
• Ability to prepare reports, testify in hearings, and defend determinations
• Proficiency in data entry and documentation systems
• Physical ability to travel, walk distances, carry equipment, and sit for extended periods

Experience:

• Medical assistance, health care services, or human services: 3 years (Required)

License/Certification:

• Registered Nurse License (RN) (Required) , PA or compact state
• Work Location: In person