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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00005081 |
Description Activated On: 1/6/2026 2:07:59 PM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. 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. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Adjudicates appeals of medical fee issues, including disputes regarding timeliness and amount of 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 hearing requests in accordance with the Workers’ Compensation Act, Medical Cost Containment Regulations, General Rules of Administrative Practice and Procedure and Commonwealth Court opinions. Directs scheduling and confirmation of hearing dates, location, recording services and participating parties. Reviews hearing transcripts, exhibits and briefs in order to circulate written decisions within ninety days of closing the evidentiary record. Decisions must include summaries of the procedural history and evidence presented; statements of issues; credibility determinations that are binding on appeal; findings of fact; conclusions of law; and an order. Maintains proficiency in medical billing and coding practices, the use of coding materials, e.g., the CPT Professional Edition coding manuals; the ICD 10-CM Complete Official Codebook; the HCPCS coding website at https://hcpcs.com; the Pennsylvania Workers’ Compensation Fee Schedule and its correlation to the applicable Medicare fee schedules; and the American College of Surgeons triage guidelines. Clarifies issues raised by Fee Review hearing requests. Performs research to determine what the actual issue(s)are in a dispute and the legal issue(s) involved. Researches existing case law, regulations, policies, and procedures pertaining to cases heard. Issues subpoenas requiring the appearance of witnesses and the production of documents, administers oaths, and examines witnesses. Rules on objections, motions and applications, either during hearings or by interlocutory order. Sets a hearing schedule, including deadlines for submission of evidence and briefs. Takes sworn testimony after administering oaths. Receives, reviews and determines the admissibility of documentary evidence, including stipulations to be incorporated into orders. Determines the credibility of witnesses and documentary evidence. Performs legal research that includes statutory provisions, case law, departmental regulations, policies and procedures. Identifies and addresses legal issues involving the complexities of the overall workers’ compensation case and how other pending litigation impacts the matter of the current litigation. Examines due process rights of parties in the context of Compromise and Release Agreements and Utilization Reviews and the issue of whether or not the litigation of a fee review matter constitutes the practice of law as it does in the litigation of a workers’ compensation matter. Interprets the Court’s rulings and applies their legal analysis in writing reasoned decisions. Tracks decisions appealed to Commonwealth and Supreme Courts. Reviews and responds to Court’s opinions in accordance with the Court’s direction. Reviews stipulations for approval and incorporation into orders. Reviews briefs and proposed findings of fact submitted by the parties. Reviews and responds to requests from litigants for appeal continuance or withdrawal. Employees in this job may be required to perform 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. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Work is performed independently and is reviewed by a supervisor through observation of hearings, review of decisions, conferences and statistical reports. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Four 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. Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. N/A 5. N/A 6. N/A |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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