Top 15 Utilization review nurse Jobs in Carlisle Pa

R&E Nurse- Med Care Services (RN) - (DOH)
QPCS —Harrisburg, PA
- $43 - $48 an hour
- Full-time
- Background check
- Nursing
- RN License
- Paid holidays
- Health insurance
Quick Apply
10d
Implementation Consultant Utilization Management
Capital Blue Cross —Harrisburg, PA
- $72,870 - $137,290 a year
- Full-time
- Remote
- Microsoft Excel
- 5 years
- Writing skills
- Paid holidays
- Health insurance
3d
Medical Records Examiner
Commonwealth of PA —Harrisburg, PA
- $69,086 - $104,959 a year
- Full-time
- RN License
- Mid-level
- Office
- Paid parental leave
- Health insurance
3d
Nurse Case Manager
Battelle —Harrisburg, PA
- Full-time
- Hybrid work
- Nursing
- RN License
- BLS Certification
- Wellness program
- Health insurance
R&E Nurse- Med Care Services (675886)
TulaRay —Harrisburg, PA
- Contract
- Nursing
- Microsoft Excel
- RN License
Quick Apply
R&E Nurse- Med Care Services (660443)
TulaRay —Harrisburg, PA
- Contract
- Nursing
- RN License
- 5 years
Quick Apply
Medical Field Case Manager
Enlyte —Gettysburg, PA
- $70,600 - $90,000 a year
- Full-time
- Hybrid work
- Nursing
- Microsoft Outlook
- RN License
- Travel reimbursement
- Health savings account
Case Manager -PRN
Helen M. Simpson Rehabilitation Hospital —Harrisburg, PA
- $40 an hour
- PRN
- Hospital
- Inpatient
- Mid-level
- Opportunities for advancement
Quick Apply
5d

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utilization review nurse jobs near carlisle pa

R&E Nurse- Med Care Services (RN) - (DOH)

QPCS -
Harrisburg, PA

Quick Apply

Job Details

Full-time
$43 - $48 an hour
10 days ago

Benefits

Paid holidays
Health insurance
Dental insurance
Paid time off
Vision insurance
401(k) matching

Qualifications

Computer operation
Nursing
RN License
Interpersonal skills
Writing skills
Clinical data entry
Attention to detail
Data interpretation
Productivity software
Stakeholder relationship building
Quality data entry
Nursing

Full Job Description

:Job Title: R&E Nurse (Review & Evaluation Nurse)
Company: Quality Patient Centered Services (QPCS)
Department: Department of Human Services (DHS), Office of Long-Term Living (OLTL), Field Operations Office (FOO) and OA - Program Integrity

Location: 555 Walnut Street, Forum Place, 6th Floor, Harrisburg, PA 17101 or OMAP - Program Integrity - 625 Forster Street, Harrisburg, PA 17120
Shift: First Shift (7:30 AM – 4:00 PM)

Compensation:

Choose the Pay Tier That Works for You

Tier 1 – W-2, benefit eligible: $43.00 per hour
Tier 2 – W-2, not benefit eligible: $46.00 per hour
1099 independent contractor: $48.00 per hour

Important 1099 Notice: Independent contractors are self-employed and are not eligible for employee benefits, paid time off, unemployment insurance, workers’ compensation coverage, or employer-paid payroll taxes. Independent contractors are responsible for their own taxes, insurance, and other applicable obligations.

About the Role

Quality Patient Centered Services (QPCS) is seeking a dedicated and detail-oriented Review & Evaluation (R&E) Nurse to support the Department of Human Services, Office of Long-Term Living. This role focuses on ensuring the quality, appropriateness, and compliance of medical services provided under the Medical Assistance Program.

Key Responsibilities

Review and evaluate medical records and documentation to determine medical necessity, quality, and appropriateness of care
Analyze provider submissions and PROMISe™ data to ensure compliance with Medical Assistance regulations
Identify potential fraud, abuse, or improper billing and recommend corrective actions
Conduct on-site, desk, and telephonic reviews of service providers
Communicate findings with providers, staff, and stakeholders, including advisory boards and legal representatives
Prepare detailed reports, correspondence, and documentation of findings
Provide consultative support to improve service delivery and administrative procedures
Serve as a team leader on complex reviews when required
Represent the Department in administrative or legal hearings as needed

Minimum Qualifications

Current Registered Nurse (RN) license issued by the Pennsylvania State Board of Nursing
OR
Non-renewable temporary practice permit (must obtain RN licensure within one year)
Three (3) years of professional experience in medical assistance (MA), healthcare services, or human services
At least three (3) years of recent (within the last five years) experience in one or more of the following:

Long-term care

Acute care

Behavioral health

Drug and alcohol services

Managed care

Quality management/utilization review

Other related clinical settings

Proficiency in writing and basic computer skills, including Microsoft Office
Knowledge of InterQual criteria, ICD-9 CM, and CPT terminology (preferred)
Ability to exercise professional judgment in identifying irregular patterns and determining appropriate actions

Essential Skills & Abilities

Strong analytical and critical thinking skills
Ability to interpret and apply healthcare regulations, policies, and standards
Effective verbal and written communication skills
Ability to establish and maintain professional working relationships
Capability to conduct fieldwork, including travel across the state (overnight stays may be required)
Ability to prepare reports, testify in hearings, and defend determinations
Proficiency in data entry and documentation systems
Physical ability to travel, walk distances, carry equipment, and sit for extended periods
Commitment to confidentiality and professional discretion

Why Join QPCS?

At Quality Patient Centered Services, we are committed to improving healthcare outcomes through integrity, compliance, and patient-centered support. Join a team that plays a vital role in ensuring quality care for vulnerable populations.

Enjoy Outstanding Benefits!

Competitive pay with full fringe benefits
Paid days off to support work-life balance
401K with company match to plan for your financial future
Paid federal holidays to enjoy with family and friends

Pay: $43.00 - $48.00 per hour

Benefits:

401(k) matching
Dental insurance
Health insurance
Paid time off
Vision insurance

Application Question(s):

Do you have knowledge of and familiarity with the following would be beneficial: Inter- Qual

criteria, ICD-9 CM, and current procedure terminology,
Ability to use professional judgment in identifying aberrant patterns and
determining the appropriate action to be taken following the documentation
review.

MUST ANSWER: 1099 Acknowledgment: If I am engaged, or elect to be engaged, as a 1099 independent contractor, I understand that I am not an employee of QPCS and am not eligible for employer-sponsored fringe benefits, workers’ compensation coverage, or unemployment compensation through QPCS, except as otherwise required by applicable law. I understand that I am responsible for my own taxes, insurance, and business expenses.

Experience:

medical assistance, health care services, or human services: 3 years (Required)

License/Certification:

Registered Nurse License (RN) (Required)

Work Location: In person

Quick Apply

Refine Your Search

utilization review nurse jobs in carlisle pa

R&E Nurse- Med Care Services (RN) - (DOH)

Implementation Consultant Utilization Management

Medical Records Examiner

Nurse Case Manager

R&E Nurse- Med Care Services (675886)

R&E Nurse- Med Care Services (660443)

Medical Field Case Manager

Case Manager -PRN

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