07/26/2013 07340

MEDICAL FEE REVIEW HEARING OFFICER

DEFINITION: This is quasi-judicial work in the adjudication of medical fee payment appeals associated with workers’ compensation claims to ensure the accurate and consistent application of relevant laws, regulations, and policies.

An employee in this job is responsible for scheduling and conducting quasi-judicial hearings to adjudicate medical fee review appeals in accordance with the medical cost containment provisions of the Pennsylvania Workers’ Compensation Act. Work involves reviewing appeals, scheduling and conducting de novo hearings, examining witnesses, receiving and analyzing testimony and exhibits, ruling on evidence and administrative procedure, and issuing written decisions and orders that are subject to appeal to Commonwealth Court. Work may include the supervision of clerical or administrative support staff. Work is performed independently and is reviewed by a supervisor through conferences and reports.

EXAMPLES OF WORK: Adjudicates appeals of medical fee issues on timeliness and amount, including disputes regarding reimbursement for services rendered to an injured worker, the application of the statute of limitations for medical fee review claims, and alleged health care provider violations of referral standards.

Conducts hearings on appeals in accordance with the General Rules of Administrative Practice and Procedure.

Issues subpoenas requiring the appearance of witnesses and the production of documents, administers oaths, and examines witnesses.

Issues adjudications and decisions that include statements of issues, findings of fact, and conclusions of law.

Researches existing case law, regulations, policies, and procedures pertaining to cases heard.

Reviews hearing records and documents and relevant departmental regulations.

Schedules and confirms hearing dates, location, recording services, and participating parties.

Reviews and responds to requests from litigants for appeal continuance or withdrawal.

Tracks decisions appealed to Commonwealth Court and reviews and responds to Commonwealth Court opinions in accordance with the Court’s direction.

Performs the full range of supervisory duties.

Employees in this job may participate in the performance of their subordinates’ work consistent with operational or organizational requirements.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of the methods and techniques of disputed case evaluation, investigation, and adjudication.

Knowledge of the methods and techniques of legal research.

Knowledge of interviewing procedures and techniques.

Ability to analyze and interpret evidence.

Ability to analyze, interpret, and apply case law to appeal cases.

Ability to analyze and interpret regulations, policies, and procedures.

Ability to establish and maintain effective working relationships.

Ability to effectively communicate orally.

Ability to effectively communicate in writing.

MINIMUM EXPERIENCE AND TRAINING: Three years of professional experience in investigative, adjudicative, or legal work analyzing and interpreting information to issue decisions, findings of fact, or determinations of eligibility, or to engage in litigation, and a bachelor’s degree;

                                                                                                                                                  or

Graduation with a law degree from a school of law accredited by the American Bar Association;

                                                                                                                                                 or

An equivalent combination of experience and training.