Behavioral Health Utilization Review Nurse (Will Train) Nurse Auditor /Utilization Review Registered Nurse (will train Home Care / Home Health RNs)   

**WILL TRAIN** Must have Home Care / Home Health  experience (excellent opportunity to transition from bedside into Utilization Review) Must have strong computer skills 

Hybrid upto 2 days in the office and remote the rest of the time. Must be willing to train in office in Harrisburg for up to 8 weeks. 

Registered Nurse Auditor Job Duties: 

• Complete retrospective audits of medical records, monitor for fraud and abuse. 
• Identify discrepancies through analysis of computer reports, claims history profiles, MCO encounter data, other documents and referrals/complaints in order to select MCO participating providers for review of compliance with program regulations and other state/federal requirements.
• Function as case coordinator for assigned cases by planning and conducting retrospective review activities to complete the case in an efficient/ timely manner.
• Perform in house and on-site reviews and recipient interviews to verify/assess the medical care rendered by providers, including the review of medical and fiscal records, MCO documentation, and MCO policy and payment information.
• Coordinate, schedule and participate in teleconferences and meetings when requested by the provider, to include physician consultant, DPW legal counsel, MCOs and provider, as applicable, to discuss review processes/case findings.
• Participate in evidentiary meetings with the Section Supervisor/Division Director, in-house medical staff, legal counsel, MCO staff, or other offices/agencies by discussing the provider case history, case strategy, and findings to recommend sanctions in accordance with Department guidelines and to prepare for litigation proceedings.
• Prepare written material in the course of the reviews by writing memoranda, letters, and reports as indicated in order to provide care findings and violations, refer information to other agencies, to communicate with recipients and providers, or to carry out necessary review activities.
• Respond to complaints from multiple sources including, but not limited to MCO, MA Provider Compliance Hotline, Tips web site, letters, e-mail and phone.
• Performs other related duties and special projects as assigned by the Supervisor in order to meet the goals and objectives.

Registered Nurse Auditor Essential Functions:

• Knowledge/use of Microsoft Office products
• Communicate effectively, verbal/written
• Prepare correspondence and reports
• Testify at legal proceedings
• Comprehend & apply rules/regulations
• Complete assignments per procedures
• Establish and maintain effective work relationships
• Maintain discretion and confidentiality
• Travel and attend on-site visits, trainings, meetings, hearings
• Physically move materials

 Registered Nurse Auditor Requirements: 

• Registered Nurse with PA license 
• Resident of Pennsylvania 
• BH or MH background and experience  
• Strong computer skills including MS Word, Excel and Outlook. 

Pay: 31.00 an hour 

Please Contact:

Katherine Skelton

586-710-0022

#ALINE01