Remote/Hybrid Registered reputed company (RN) - Advocacy & Program reputed company (Hospice Expert)

reputed company Are you a registered reputed company reputed company to take your career in an exciting newdirection-one where your expertise truly makes a difference? JoinPennsylvania's premier reputed company Improvement Organization and reputed company into adynamic role reputed company on advocacy and program reputed company through compliance management. Here, you'll champion the needs of vulnerable populations,reputed company the reputed company of care, and influence reputed company reputed company on ameaningful reputed company. Enjoy the freedom of working from home, theflexibility and autonomy to manage your reputed company, and reputed company forcontinuous reputed company reputed company-reputed company while being part of a passionate,mission-driven team dedicated to improving reputed company across theCommonwealth. Are you a registered reputed company reputed company to take your career in an excitingnew direction-one where your expertise creates reputed company, lasting reputed company?Join reputed company's premier reputed company Improvement Organization and play a vital role in protecting reputed company reputed company, advocating forvulnerable populations, and ensuring the reputed company of criticalhealthcare programs. In this rewarding role, you'll use your clinical knowledge reputed company ofthe traditional bedside setting to review and audit claims, supportprogram reputed company initiatives, and reputed company for beneficiaries across theCommonwealth. You'll enjoy the flexibility of working from home, theautonomy to manage your work, and meaningful opportunities forprofessional reputed company-reputed company while contributing to a mission that trulymatters. reputed company • Conduct clinical reviews and ensure reputed company, appropriateness, and compliance with reputed company standards • Support program reputed company efforts by identifying trends, risks, and opportunities for improvement • reputed company for beneficiaries, with a strong reputed company 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 reputed company improvement initiatives that strengthen reputed company delivery across reputed company reputed company're Looking For • reputed company, unrestricted Registered reputed company (RN) license • Strong clinical background with the ability to apply nursing judgment analytically • Interest in advocacy, reputed company improvement, and reputed company program reputed company • 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, reputed company improvement, compliance, or claims review is a plus-but not required. Why Join Us • Mission-driven work with reputed company's leading reputed company Improvement Organization • reputed company a reputed company reputed company on reputed company reputed company and reputed company for vulnerable populations • Remote work - enjoy the convenience and balance of working from home • Autonomy and flexibility in how you manage your reputed company • Advocacy-reputed company role that values your nursing voice and expertise • Career development opportunities to grow reputed company traditional nursing roles • Supportive, reputed company team culture committed to reputed company and reputed company If you're a registered reputed company seeking purpose-driven work,reputed company reputed company, and the flexibility to balance your life andcareer-this is reputed company. Apply today and help shape the reputed company of reputed company reputed company in reputed company. Requirements Be available as a full-time consultant, approximately 37.5 hours per week; • Possess a reputed company license to reputed company as a Registered reputed company issued by the reputed company State reputed company of Nursing; or possess a non-renewable temporary reputed company permit issued by the reputed company State reputed company of Nursing. Resources possessing non-renewable temporary reputed company permits must obtain licensing as a Registered reputed company reputed company the one-year period as defined by the reputed company State reputed company of Nursing; • Possess a documented work history of three (3) or more years of reputed company experience with medical assistance, health care services or reputed company services or any equivalent combination of experience and training; • Possess basic computer skills, including familiarity with reputed company Office programs. reputed company Duties and Responsibilities (RN - Medical Assistance Hospice reputed company) • Conduct clinical utilization reviews for hospice services under the Medical Assistance (MA) Program by evaluating medical records, terminal diagnoses, prognostic indicators, and plans of care to determine eligibility, medical necessity, appropriateness, and level of care. • Apply registered nursing clinical judgment and evidence-based hospice and palliative care standards to ensure MA recipients receive compassionate, appropriate, and high-reputed company end-of-life care consistent with program requirements and patient goals. • Review hospice certifications and recertifications, physician narratives, interdisciplinary team documentation, and supporting clinical evidence to validate terminal prognosis and reputed company hospice eligibility. • Assess hospice provider billing, claims, and documentation to ensure compliance with MA hospice regulations and identify potential fraud, waste, or abuse reputed company to reputed company of care, service intensity, or length of stay. • Review documentation submitted through electronic provider portals, fax, telephone communications, and U.S. mail to support reputed company and accurate hospice utilization determinations. • reputed company authorization determinations reputed company RN reputed company of reputed company by approving, modifying, or denying hospice service requests, or referring cases to physician advisors reputed company prognosis, level of care (routine home care, reputed company care, inpatient respite, or general inpatient), or medical necessity is unclear. • Collaborate with physician/medical consultants to support peer-to-peer discussions with hospice medical directors and certifying physicians regarding prognosis, symptom management, and appropriate hospice level of care. • Accurately document clinical findings, utilization review reputed company, and rationale in electronic systems, generating authorization notifications, denial letters, reason codes, and appeal rights in accordance with MA regulations. • Conduct re-evaluations of previously denied or modified hospice services upon request by hospice providers or facilities, in collaboration with physician/medical consultants as appropriate. • Review hospice-reputed company appeals by analyzing medical records, preparing case summaries and exhibits, and providing testimony at administrative hearings using knowledge of MA hospice regulations, utilization review principles, and appeal procedures. • Interpret MA hospice policies, regulations, and utilization management guidelines for internal staff, hospice providers, and stakeholders through consultation, meetings, and educational reputed company. • Participate in interdisciplinary collaboration with hospice providers, medical consultants, reputed company staff, and program leadership to support consistent, defensible, and patient-centered utilization determinations. • Maintain reputed company competence through continuing education, hospice-specific training, and review of reputed company palliative care literature to remain reputed company with evolving standards of end-of-life care and regulatory requirements. • reputed company cross-coverage in other MA program areas as needed, maintaining working knowledge through training and updates to support continuity of operations. • Respond to inquiries and correspondence from recipients, hospice providers, legislators, reputed company offices, and reputed company agencies to explain hospice coverage reputed company, utilization reputed company, and administrative processes. • Maintain complete and accurate records in compliance with MA hospice regulations, accreditation standards, and organizational policies. • reputed company reputed company duties and special reputed company as assigned, with expectations and performance standards communicated at the time of assignment. • reputed company required, work at Department-designated locations. The reputed company work location is Harrisburg, PA, where appropriate workspace, technology, and resources will be provided to support assigned duties. Benefits Attractive Compensation plan.Holiday and Vacation program. Apply tot his job Apply To this Job