Remote/Hybrid Registered Nurse (RN) – Advocacy & Program Integrity (Long Term Living Expert)

Are you a registered nurse ready to take your career in an exciting new direction—one where your expertise truly makes a difference? Join Pennsylvania’s premier Quality Improvement Organization and step into a dynamic role focused on advocacy and program integrity through claims auditing. Here, you’ll champion the needs of vulnerable populations, safeguard the quality of care, and influence healthcare outcomes on a meaningful scale. Enjoy the freedom of working from home, the flexibility and autonomy to manage your workday, and the opportunity for continuous professional growth—all while being part of a passionate, mission-driven team dedicated to improving healthcare across the Commonwealth. 

Are you a registered nurse ready to take your career in an exciting new direction—one where your expertise creates real, lasting impact? Join Pennsylvania’s premier Quality Improvement Organization and play a vital role in protecting healthcare quality, advocating for vulnerable populations, and ensuring the integrity of critical healthcare programs.

In this rewarding role, you’ll use your clinical knowledge outside of the traditional bedside setting to review and audit claims, support program integrity initiatives, and advocate for beneficiaries across the Commonwealth. You’ll enjoy the flexibility of working from home, the autonomy to manage your work, and meaningful opportunities for professional growth—all while contributing to a mission that truly matters.

What You’ll Do

• 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
  

What We’re Looking For

• 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
  

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

Why Join Us

• Mission-driven work with Pennsylvania’s leading Quality Improvement Organization
  

• Make a real impact on healthcare quality and outcomes for vulnerable populations
  

• Remote work – enjoy the convenience and balance of working from home
  

• Autonomy and flexibility in how you manage your workday
  

• Advocacy-focused role that values your nursing voice and expertise
  

• Career development opportunities to grow beyond traditional nursing roles
  

• Supportive, collaborative team culture committed to excellence and integrity
  

If you’re a registered nurse seeking purpose-driven work, professional growth, and the flexibility to balance your life and career—this is your opportunity. Apply today and help shape the future of healthcare quality in Pennsylvania.

Requirements

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.

• Evaluate and review medical, physical, rehabilitative, restorative, and other care being provided to determine appropriateness.
  

• Review, understand and relate pertinent Departmental, State and Federal policies, licensing requirements, and regulations to ensure compliance by Medical Assistance (MA)/OLTL providers.
  

• Participate in the development of new and/or revision to existing medical assistance policies and regulations.
  

• Coordinate and interact with other Agencies and Departments to ensure appropriate services for individuals using long term living services.
  

• Perform monitoring reviews in all Long-Term Living settings to determine that the provision and adequacy of medical, social, physical, rehabilitative, and restorative care services are being provided in accordance to all regulations and licensing criteria.
  

• Review Minimum Data Set (MDS) submitted to the MDS database for accuracy and documentation support in the clinical records.
  

• Review PA Pre-Admission Screening Resident Review (PA-PASRR-ID) process to assure nursing facilities (NF) compliance with the Omnibus Budget Reconciliation Act (OBRA).
  

• Perform evaluations of identified targeted individuals residing in long term care facilities including submission of packet with recommendations to the appropriate Program Office (OMHSAS, ODP, ORC, or DMVA) for review.
  

• Monitor appropriateness of NF admissions and determine need for continued stay by reviewing clinical records, evaluate discharge plans and interview staff and residents.
  

• Perform financial reviews to identify recoveries to ensure adjustments are made for any inappropriate payments or billings in accordance with established regulations and guidelines.
  

Benefits

Attractive Compensation plan.  Holiday and Vacation program.