Utilization Review Nurse - $33.70 per hour/ Full-time Role - Hybrid

Location: Harrisburg
Posted on: June 23, 2025

Job Description:

Consultant will: Be available as a full time consultant approximately 37.5 hours per week; Possess an active Pennsylvania Registered Nurse License issued by the Pennsylvania State Board of Nursing; or possesion of a non-renewable temporary practice permit issued by the Pennsylvania State Board of Nursing. Resources possessing non-renewable temporary practice permits must obtain licensure 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 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 familiarty with Microsoft Office programs; Perform review and evaluation of medical information and examination of medical records to assure the medical necessity, appropriateness, quality, quantity, adequacy and compensability of medical care and services under the Medical Assistance Program; Responsible for the review and evaluation of medical information and examination of medical records and other documentation to assure that eligible medical assistance recipients receive appropriate and quality medical care, that the MA program is properly billed, and that provider and/or recipient fraud and abuse of the MA program is detected and corrected. Documentation submitted by the MA service providers and generated thru the Departments payment system is analyzed and evaluated. These documents can be provided over the phone, by fax and/or US mail. Provide problem solving solutions to supervisor and Division Director to improve the services or administrative procedures in support of MA patients. Perform other related duties as assigned by the managerial staff. Approve, approve other than as requested, and deny requests or refer the request to a physician consultant to discuss the medical necessity of the requested service, appropriate setting, and/or the compensability of the service. Consult with the physician/medical consultant on cases for which the medical need for the requested services/items is unclear and arranges telephone calls between the physician consultant and the ordering physician for further discussion of the need for the service/item or for further discussion on the appropriate setting for the service. Enter the appropriate data and decision into the computerized system, which generates notification letters to the practitioner, provider, facility, and/or recipient to provide the authorization number for billing purposes, the reason code for denials, and the appeal process. Consult with the physician/medical consultant when a re-evaluation of a case is requested by a practitioner, provider, or facility to reconsider a previously denied service. Evaluate appeal requests and medical records; prepares cases, exhibits and appeal correspondence; testify at appeal hearings by utilizing knowledge of MA regulations and appeal procedures; and prepare petitions for Reconsiderations. Interpret MA policies, regulations and procedures to agency or office staff via telephone conversations. Attends workshops, and/or meetings to ensure a working knowledge in these areas. Attend staff meetings for the purpose of information sharing regarding MA policies, regulations, and review procedures. Maintain continuing education through conferences and the reading of medical journals and documents to keep abreast of current trends for treatment of medical conditions to ensure that proper decisions regarding medical necessity and appropriateness of services is met. Relieve in other sections as required in order to maintain all program functions. Updates and training in the processes will be scheduled as necessary to ensure a working knowledge in the different areas. Respond to inquiries/correspondence from recipients, providers, legislators, legal office and other agencies concerning the program in order to explain regulations, operational methods, and administrative procedures and decisions. Files and retains records in accordance with MA regulations and policies. Performs related work as required and special projects as assigned. Purpose and standards are given at the time of each assignment. Consultant will be provided with a desk, computer, and all items necessary for him/her to complete assignments. Additional work/duties for the Inpatient Clinical Review Section: Performs an admission review of all urgent and emergency admissions to general hospitals and short procedure units; and/or elective admissions to medical rehabilitation hospitals; to evaluate the medical necessity and the appropriate setting for the services to ensure that the admission is medically necessary and compensable under the MA program. Reviews and evaluates medical information given by the facility during the scheduled call or via the electronic review form to assure that care is certified for payment at the rate for the appropriate setting and is in accordance with applicable State and Federal MA laws and regulations. Certifies urgent and emergency admissions and/or medical rehab admissions, or refers the request to the physician consultant for the appropriate setting or compensability of the case.

Keywords: , Wilmington , Utilization Review Nurse - $33.70 per hour/ Full-time Role - Hybrid, Healthcare , Harrisburg, Delaware