R&E Nurse- Med Care Services- Expert
Possession of a current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing; or Possession of a non-renewable temporary practice permit issued by the Pennsylvania State Board of Nursing. Resources possessing non-renewable temporary practice permits must obtain licensure as a Registered Nurse within the one-year period as defined by the Pennsylvania State Board of Nursing.
Proficient writing and basic Computer Skills to include, but not limited to, Microsoft Office Products
Three years of professional experience with medical assistance (MA), health care services, or human services
Minimum of three years of recent (within the last five years) professional experience in one or more of the following areas as related to the position need: long term care, acute care setting, behavioral health setting, drug and alcohol setting, managed care, quality management/utilization review or other related clinical experience; or
An equivalent combination of experience and training in the field of medical assistance (MA), health care services, human services, long term care, utilization review, or knowledge of home care
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.
This is work in the review and evaluation of the medical necessity, appropriateness, quality, quantity, adequacy, and compensability of medical care and services rendered by service providers under the Medical Assistance Program. A resource is responsible for the review and evaluation of medical information and examination of medical records and other documentation to assure that eligible medical assistance recipients receive appropriate and quality medical care that the Medical Assistance Program is properly billed, and that provider and/or recipient fraud and abuse of the Medical Assistance Program is detected and corrected. Work involves the analysis and evaluation of documentation submitted by Medical Assistance Program service providers and generated through PROMISe' in order to make professional medical judgments regarding the appropriateness of the care and services provided to eligible recipients under the Medical Assistance Program. Reviews may be conducted in central office with the Medical Assistance Program service provider furnishing the necessary medical records, on site at the facility, or information may be provided over the telephone for any service that may require prior authorization or post certification. Work may include serving as a team leader on reviews requiring more than one staff member organizing and coordinating the review process. Resources also provide advisory and consultative services to boards and staff designed to improve the services or administrative procedures in support of medical assistance patients. Work may also involve the resource representing the Department in an official capacity during an appeal process. Judgment and discretion are required in conferring with advisory boards, facility officials, providers, and staffs. Work is performed under the supervision of an administrative superior and is reviewed through conferences and reports.
ESSENTIAL JOB FUNCTIONS*
Ability to prepare correspondence and reports.
Ability to comprehend and apply regulations, policies and standards. Ability to establish and maintain effective working relationships. Ability to carry out instructions and complete assignments. Ability to conduct field work, desk and telephonic reviews.
Ability to travel to facilities/provider sites to conduct reviews and attend training and meetings as needed, across the State (includes overnight stays). Ability to communicate effectively (verbally and in writing) with coworkers, management, Office of General Counsel other agencies, nursing facility staff and other medical assistance providers to review and discuss cases.
Ability to enter essential data into the computer.
Ability to physically traverse stairs, lift laptop, printer and related equipment, walk long distances and sit for long periods of time.
Ability to review and evaluate provider documentation to determine compliance with Medical Assistance regulations.
Ability to testify at administrative/legal hearings and to defend Departmental decisions.
Ability to maintain discretion and confidentiality.
*Essential Job Function: A necessary and fundamental job duty associated with the position.