Claims Review Management Nurse (RN)

Job Description

Job Description

We are seeking an experienced Claims Review Management Nurse (RN) to support the Pennsylvania Medicaid program in a long-term, full-time contract role based in Harrisburg, PA, with a hybrid schedule (three days remote, two days onsite). This position plays a critical role in overseeing claims review processes, supporting operational improvements, and collaborating with leadership and stakeholders to ensure efficient and compliant program operations.

The ideal candidate will bring an active Pennsylvania RN license along with at least five years of experience in claims review, coding, or claims processing. Strong knowledge of HCPCS II, CPT, or dental coding is required, along with familiarity with Medicare and Medical Assistance guidelines. Experience working within systems such as PROMISe or similar claims platforms, as well as proficiency in Microsoft Office tools (Excel, Word, PowerPoint), is essential for success in this role.

In this position, you will review, analyze, and process medical claims while providing operational input and guidance on claims decisions. You will contribute to coding activities, assist with procedure code groupings, and support annual coding updates for the Pennsylvania Medical Assistance program. The role also involves evaluating current workflows, identifying opportunities for improvement, and participating in system enhancements related to provider enrollment, inquiries, and medical review functions.

Additionally, you will collaborate with senior leadership to identify operational challenges and develop data-driven solutions, participate in cross-functional work groups and project teams, and serve as a liaison between the Department of Human Services and external stakeholders. Responsibilities also include assisting with policy research, reviewing regulations and criteria, and contributing to studies or comparisons that support program effectiveness and compliance.

This role requires the ability to work both independently and collaboratively, managing assignments with minimal supervision while contributing to broader team initiatives. You will be provided with the necessary equipment and will be expected to work onsite in Harrisburg two days per week, with flexibility for telework based on program needs.