About this position
Job Description
Job Description
Position Overview
We are seeking an experienced Registered Nurse (RN) – Expert Medical Examination Consultant to support medical review and program integrity initiatives within a full-time, long-term contract opportunity based in Harrisburg, Pennsylvania.
This position offers a hybrid work schedule, consisting of three remote workdays and two onsite workdays per week.
The selected candidate will perform comprehensive clinical and administrative reviews to evaluate medical necessity, quality and appropriateness of care, accuracy of medical documentation, and compliance with applicable state and federal healthcare regulations.
Key Responsibilities
The RN Expert Medical Examination Consultant will be responsible for:
- Medical Record Reviews
- Conduct comprehensive medical record reviews and clinical assessments.
- Evaluate patient documentation to determine medical necessity and appropriateness of services provided.
- Assess the accuracy, completeness, and consistency of clinical records.
- Claims Review & Evaluation
- Review and evaluate healthcare claims for accuracy and compliance.
- Examine medical coding and supporting documentation.
- Identify potential discrepancies, inappropriate billing practices, and areas requiring further investigation.
- Program Integrity & Compliance
- Identify potential indicators of fraud, waste, and abuse (FWA).
- Evaluate provider documentation and clinical practices for compliance with state and federal healthcare regulations.
- Identify potential quality-of-care concerns and recommend appropriate follow-up actions.
- Clinical Data Analysis & Reporting
- Analyze clinical information, healthcare utilization trends, and provider documentation.
- Prepare detailed review findings, reports, and recommendations.
- Support corrective actions, compliance initiatives, and program oversight activities.
- Collaboration & Consultation
- Work collaboratively with compliance teams, investigators, auditors, and medical directors.
- Participate in case discussions, clinical consultations, and reviews involving complex medical scenarios.
- Provide clinical insight and recommendations to support informed decision-making.
- Appeals & Follow-Up Reviews
- Assist with appeals, additional documentation reviews, and follow-up assessments.
- Provide guidance regarding medical necessity criteria and documentation requirements.
- Support the resolution of identified clinical and administrative concerns.
- Confidentiality & Professional Standards
- Maintain strict confidentiality when handling sensitive medical records and patient information.
- Follow established healthcare compliance standards, policies, and procedures.
- Manage multiple assignments independently while meeting deadlines and maintaining accuracy.
Ideal Candidate Qualifications
The ideal candidate will demonstrate:
- Strong clinical knowledge and professional nursing experience.
- Excellent analytical, critical-thinking, and problem-solving skills.
- Experience reviewing medical records, healthcare claims, or clinical documentation.
- Knowledge of medical necessity requirements and healthcare regulations.
- Ability to identify documentation discrepancies and potential compliance concerns.
- Strong written and verbal communication skills.
- Ability to work independently, prioritize assignments, and manage multiple responsibilities in a fast-paced, compliance-driven environment.
Work Schedule & Location
- Position: Registered Nurse (RN) – Expert Medical Examination Consultant
- Employment Type: Full-Time
- Duration: Long-Term Contract
- Location: Harrisburg, Pennsylvania
- Work Arrangement: Hybrid
- Remote Schedule: Three days per week
- Onsite Schedule: Two days per week
Position Objective: To strengthen healthcare program integrity through detailed clinical examinations, medical record reviews, claims evaluations, and regulatory compliance assessments while supporting the delivery of appropriate, medically necessary, and quality healthcare services.
\nCompany DescriptionPleasant office environment. The CK Hobbie Group is a fifty-six year old recruiting and staffing business
Company Description
Pleasant office environment. The CK Hobbie Group is a fifty-six year old recruiting and staffing business
Location and commute
Harrisburg, PA .
Plan your route with Google Maps. Travel times and transportation options vary; confirm the work location with the employer before commuting.
How to apply
Review the vacancy and complete the application on the employer or recruitment partner’s website. Requisition ID: WJ-3267055448.