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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00013288 |
Description Activated On: 12/30/2025 8:45:16 AM |
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. This position is the Supervisor of the Integrity Management Section within the Bureau of Program Integrity. Acts as the Program Integrity liaison for all PROMISe related issues, resource coordination, and enhancement requests. Directs, manages, and oversees the activities of subordinate staff such as Human Services Program Specialists, Quality Improvement Information Specialist, and Medical Economists. |
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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. This position is responsible for the oversight, direction, and management of the following activities: Oversight of reporting data such as claims, encounters and internal and external data requests related to fraud, waste and abuse. Respond to and resolve provider and beneficiary complaints. Processing and compliance of the Deficit Reduction Act Attestations All Bureau Claim and Gross Adjustment entries input into PROMISe Bureau Claims resolution and tracking Support and control of Claims and Encounters related to Prepayment Reviews and Payment Suspensions for credible allegations of fraud. Account Receivables Reconciliation and Resolution Bureau Recovery reporting Bureau PROMISe Training Coordination Bureau Employee Out-Service Education and Development Support Bureau representation and participation in Fee for Service and Managed Care Data Workgroups Bureau PROMISe Edit Management Update, maintenance and support of the precluded provider list (Medicheck), which supports PROMISe claims processing and the public Medicheck list on the DHS website Oversee all preclusion/exclusion activities for the Bureau, including DEX certifications, TIBCO/MFT file support, maintenance of the Invalid License table in PROMISe and processing of State, Federal and reciprocal State actions. Bureau HIPAA Coordination and staff support Bureau representation and participation in the Provider Action Team Bureau representation and participation in the Third Party Liability Action Team Oversee triage and assignment of all incoming FWA referrals from various areas including MCO, other State agencies, the OMAPTips website and the DHS TIPS hotline. Provider Targeted Self-Audits MQC/TPL Case Referrals Claims and encounter data support of all Centers for Medicare and Medicaid Services (CMS) initiatives as they relate to Fraud and Abuse Works in a cooperative manner, with Bureau review staff to provide information necessary to conduct reviews of MA Providers and MA recipients to determine if they are in compliance with applicable law, regulation and policy. Works to design, develop, implement and maintain additional new systems to enhance workflow, productivity and encourage efficiencies on a bureau-wide basis. Works to design, develop and implement new algorithms for fee for service and managed care claims in order to proactively identify fraud, waste and abuse in the Medical Assistance Programs. Internal and external audit coordination for the Bureau. Fraud and Abuse Detection SURS project manager. Addresses provider balance billing issues and complaints. Recording, tracking and deposit of checks received for Bureau cases |
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. Works independently within established guidelines to meet the goals and objectives of the Bureau. Uses appropriate judgment and discretion in bringing matters to Executive Staff for further direction and guidance. Able to lead large projects through all claims and encounter data related and technical design related activities to insure successful and timely completion. Able to review assignments of subordinates and give direction with minimal supervision from Director. Ensure that all target dates for completion of assignments are completed in a timely manner or if not, updated target dates are clearly communicated to affected parties in a timely manner. |
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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: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. 5. 6. |
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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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