Remote/Hybrid Registered Nurse (RN) – Advocacy & Program Integrity (Medical Assistance- Med Surg Hospitalization Expert)

A Pennsylvania-based quality improvement organization focused on healthcare program integrity, advocacy, and improving care for vulnerable populations; hires nurses for remote utilization review and quality roles.

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 compliance management. 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. • Principal Duties and Responsibilities (RN – Medical Assistance Inpatient Utilization Review & Discharge Planning) • Conduct clinical utilization reviews for medical–surgical inpatient hospitalizations under the Medical Assistance (MA) Program by evaluating medical records, admission criteria, continued stay indicators, and treatment plans to determine medical necessity, appropriateness, and level of care. • Apply registered nursing clinical judgment and evidence-based medical–surgi