JOB TITLE: MEDICAL RECORDS EXAMINER

JOB CODE: 39570

SERIES NATURE OF WORK: The Medical Records Examiner job series describes work in regulating the provision of medical care and services under the Commonwealth medical assistance program and Pennsylvania (PA) Workers’ Compensation Act.

DEFINITION: This is professional regulatory nursing work in evaluating the medical necessity, appropriateness, quality, and compensability of care and services provided under the Commonwealth medical assistance program or PA Workers’ Compensation Act.

An employee in this job evaluates medical information and records to ensure medical assistance patients receive appropriate and quality medical care, that the medical assistance program is properly billed, and provider or patient fraud and abuse of the program is identified and addressed. Work involves analyzing documentation submitted by program service providers and other data to make professional medical judgments regarding care and services provided. Work may include serving as a team leader on reviews, organizing and coordinating the review process, and providing advisory and consultative services to boards and staff to improve services or administrative procedures. Employees performing work under the PA Workers’ Compensation Act review and evaluate claims for appropriateness, medical necessity, and coverage; evaluate utilization review requests and determinations for appropriateness and medical necessity; and conduct medical fee reviews to determine whether fees paid to health care providers are timely and accurate. Work is performed under the supervision of an administrative supervisor and is reviewed through conferences and reports.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.)

• Compiles and prepares medical records and related documentation for reports conveying noncompliance with medical assistance program regulations by service providers or eligible patients; recommends the appropriate administrative action or referral to the appropriate legal entity for action.

• Evaluates medical records and documentation for services considered necessary and appropriate under the medical assistance program and recommends proper reimbursement.

• Examines medical documentation for nursing home residents to determine whether continued nursing home placement is appropriate and recommends appropriate placement.

• Evaluates medical information and discusses cases with hospital utilization review staff, physician office staff, or other medical professionals to certify the medical necessity, length of stay, and compensability of inpatient hospital or same-day surgery admissions and for services that require prior authorization.

• Analyzes program data to determine specific areas for further review based upon trends in diagnosis, treatments, prescriptions, and other possible indicators, and participates in the development of these reports.

• Investigates cases of suspected fraud or abuse to gather evidence for use in administrative or legal actions.

• Discusses review findings with service providers and advises them on compliance with medical assistance program regulations and procedures.

• Researches, prepares information, and provides testimony in hearings.

• Communicates medical assistance program policies, regulations, and procedures to service providers.

• Provides clinical guidance in the development and revision of medical assistance program provider handbooks and the Medical Assistance Program Fee Schedule.

• Provides consultation and technical assistance to insurance companies, attorneys, injured workers, and health care providers during the medical treatment review process.

• Compares determinations made by utilization review organizations for conformance with the medical cost containment rules and regulations.

• Evaluates applications for certification to operate as a utilization review organization or peer review organization under the Workers’ Compensation Act.

• Assesses medical fee review forms, medical bills, medical reports, legal documents, workers’ compensation forms, and other documentation based on the requirements of the Pennsylvania Workers’ Compensation Act, the National Medicare Correct Coding Initiative, current AMA coding practices, and current medical practice standards to determine appropriate payment amounts and timeliness.

• Verifies that the applicable International Classification of Disease (ICD) codes are indicated on workers’ compensation claims for proper transmission to Medicare.

• Evaluates case information; determines the need for medical records reviews, independent medical examinations, or utilization reviews; and requests these investigations when necessary.

• Determines what diagnoses are related to the work injury, reviews medical billing, determines coding, and approves payments.

• Travels to field sites to conduct reviews and investigations.

• Performs related work as required.

ENTRY-LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the principles and standards of nursing care and related patient service.

• Knowledge of common medical diagnoses and the associated treatments and services provided in relation to these diagnoses.

• Knowledge of current trends in health care service delivery.

• Knowledge of the principles and standards of health care practices and patient care.

• Knowledge of medical coding.

• Knowledge of the theories and practices of preventive health care.

• Knowledge of disease and disorder processes and their signs and symptoms.

• Knowledge of techniques used to establish, monitor, and evaluate medical treatment plans and medical records.

• Knowledge of the theories and practices of pharmacology.

• Knowledge of individual and group behavior.

• Knowledge of the use and functionality of Microsoft Office Suite software.

• Ability to analyze and interpret laboratory and diagnostic tests.

• Ability to analyze and interpret written and numerical information.

• Ability to operate a motor vehicle.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

• Ability to establish and maintain effective working relationships.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities)

• Three years of professional experience in the field of medical assistance, health care services, or human services;

or

• An equivalent combination of experience and training.

SPECIAL REQUIREMENTS:

• All positions require active authorization to practice as a Registered Nurse in Pennsylvania.

• All employees possessing an active temporary practice permit must obtain licensure as a Registered Nurse within the one (1) year period defined by the Pennsylvania State Board of Nursing.

• Certain positions require an active motor vehicle license.