A-Line Staffing is now a motivated and detail-oriented Remote Medicaid Clinical Review Nurse (RN) – MUST BE IN PENNSYLVANIA Please contact Marcia Hamilton at (586) 710-7979 or mhamilton@alinestaffing.com

Medicaid Clinical Review Nurse (RN)
Location: Pennsylvania (Residency Required)
Work Hours: Monday – Friday, 7:30 AM – 4:00 PM (1-hour lunch)
Position Type: Full-time

Payrate: $32.00 an hour

Job Description

We are seeking a dedicated and experienced Registered Nurse to join our team as an Inpatient Clinical Review Nurse within the Medical Assistance Program. This role focuses on ensuring the quality, appropriateness, and medical necessity of services rendered to eligible recipients across various healthcare settings.

As part of the Inpatient Clinical Review Section, your responsibilities will include analyzing and evaluating medical documentation and records, identifying aberrant utilization patterns, and contributing to the prevention of fraud and abuse in the Medical Assistance Program.

Minimum Qualifications

• Current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing, or

Preferred Knowledge/Skills

• Familiarity with InterQual criteria, ICD-9-CM, and CPT coding.
• Knowledge of medical assistance policies and procedures.
• Sound professional judgment to identify compliance and potential irregularities in documentation.
• Experience conducting prior authorization or post-certification reviews.

Essential Job Functions

• Conduct field, desk, and telephonic reviews of provider documentation.
• Travel to provider sites and attend meetings/trainings throughout the state (overnight travel required).
• Evaluate documentation for compliance with MA regulations.
• Communicate effectively with internal staff, legal teams, and healthcare providers.
• Testify in administrative/legal hearings.
• Maintain confidentiality and discretion in all professional activities.
• Ability to work independently and collaboratively within a team.

A-Line Staffing is now a motivated and detail-oriented Medicaid Clinical Review Nurse (RN) – MUST BE IN PENNSYLVANIA Please contact Marcia Hamilton at (586) 710-7979 or mhamilton@alinestaffing.com