Primary Care Physician (PCP) NDC- Expert
Pay Rate: $99 / hour
Evaluations conducted by primary care physician. Maximum hours per year of 10-12 hours annually
Be board certified in family practice medicine. Possess an active
Pennsylvania medical license. If feasible, be in active clinical practice in the area in which the Resource is board certified at least sixteen (16) hours per month. Demonstrate an understanding of utilization review processes.
Basic computer skills to include, but not limited, to Microsoft Office Products.
Resource will provide utilization and quality reviews of services for the Department. Resource will conduct prospective, concurrent and retrospective review of any assigned adult and pediatric inpatient and outpatient medical cases covered by the Department including, but not limited to: inpatient admissions;procedures performed in a physician's office, Short Procedure Unit or Ambulatory Surgical Center;home health services, medical supplies, and/or diagnostic studies or procedures.
Resource shall be responsible for making determinations regarding the medical necessity, place of service, appropriateness, compensability, and/or quality of care of services prescribed for and provided to Medicaid recipients.
It will be the Resource's responsibility to review all requests thoroughly and make a qualified determination in accordance with Medical Assistance regulations and criteria. Depending on the type of case reviewed, Resource will be required to compile case findings, prepare summaries of case findings;make recommendations for case disposition, identify program violations;prepare appealed cases for hearings;and/or be available to testify at administrative hearings for cases under appeal.
The Resource will submit the above information to the Department using formats specified by each individual Bureau.
Resource, when requested, will assist in the development of in-house training programs, medically necessary criteria, and quality of care indicators.
Resource may be asked to help the Department in determining if any changes should be made to criteria or regulations to better serve Medical Assistance recipients.