JOB TITLE: MEDICAL RECORDS EXAMINER SUPERVISOR

JOB CODE: 39580

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

An employee in this job supervises staff engaged in the evaluation of medical information and records to ensure medical assistance program compliance and adherence to the PA Workers Compensation Act. Work involves planning and providing training programs for subordinate staff and developing standards and procedures pertaining to specific service provider review programs. Work performed under the medical assistance program includes ensuring the program is properly billed for services rendered; and ensuring that provider and recipient fraud and abuse is detected and referred for appropriate action. Work performed under the PA Workers’ Compensation Act includes ensuring adherence to the workers’ compensation medical fee schedules and medical cost containment rules and regulations; and ensuring that medical care provided to workers’ compensation patients is rendered based upon medical necessity. Work is performed under the direction of an administrative supervisor and is reviewed through reports and conferences for the achievement of goals, objectives, and quality.

   DISTINGUISHING CHARACTERISTICS:

     • Work is distinguished from the lower-level job based on the supervision of Medical Records Examiners (commonwealth title).

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.)

• Plans, organizes, prioritizes, assigns, and reviews the work of staff engaged in the examination and evaluation of medical records, invoices, and related documentation used to assess the medical necessity, appropriateness, quality, and compensability of medical care and services rendered by service providers under the Commonwealth medical assistance program or the PA Workers’ Compensation Act.

• Plans and directs medical record reviews and surveys at provider facilities or in central office which involve the collection, analysis, and evaluation of medical data to determine medical necessity, appropriateness, quality, and compensability of medical care and services.

• Interprets the rules, regulations, policies, standards, and objectives of the medical review programs and conveys them to staff, providers, and other interested parties.

• Participates in the development and implementation of medical review processes and standard policies and procedures pertaining to the Commonwealth medical assistance program or the PA Workers’ Compensation Act.

• Provides consultative services to hospitals, administrators, boards, homes, and other service providers.

• Meets with hospital administrators, physicians, health insurance representatives, and other service providers relative to the medical review programs.

• Travels to field sites to conduct reviews and investigations.

• 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.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

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

• Knowledge of the principles and practices of nursing administration.

• Knowledge of the principles and practices of health insurance administration.

• Knowledge of rules, regulations, policies, and procedures related to the Commonwealth medical assistance program or PA Workers’ Compensation Act.

• 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 medical records and reports.

• 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)

• One year as a Medical Records Examiner (Commonwealth title);

or

• Four 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.