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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00034174 |
Description Activated On: 5/21/2025 1:04:05 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. This is a professional level position in the Office of Long-Term Living (OLTL), within the Division of Provider Operations. This position is responsible for analyzing, developing, implementing, coordinating, monitoring, and evaluating OLTL programs and processes and is responsible for providing technical and analytical assistance to all OLTL providers. The employee encourages the development of other long-term care options across the Commonwealth; analyzes, reviews, develops, and monitors policies and procedures, prepares reports and serves as the lead for provider overpayment recovery and compliance initiatives. |
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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. Responsibilities include the following: Maintains working knowledge of Medical Assistance (MA) regulations at 55 Pa. Code Chapters 52, 1101, 1187, and 1189 regulations, governing Nursing Facilities (NF), ICF/IDs, Home and Community Based (HCBS) providers, and LIFE providers. Responsible to review, analyze, coordinate, and implement internal processes due to provider non-compliance related to corrective action plans (CAP) referred to the Division of Provider Operations by the Division of Fee-for-Service Programs Quality Management Efficiency Teams (QMET). This includes but is not limited to review, analysis, processing, monitoring, tracking, and reporting of overpayment recovery efforts to address provider non-compliance. Identify, coordinate, and impose adverse actions against OLTL providers if applicable. Responsible to review, analyze, coordinate, and implement internal processes to address OLTL provider Accounts Receivables (AR) that have not automatically offset through the claims process. Responsible for tracking, monitoring, and reporting on recoupment efforts. Review and provide recommendations on the internal process for improvements and will be responsible to implement updates to the process. Responsible for reviewing, processing, and tracking provider financial transactions through gross adjustments in PROMISe. This includes but is not limited to calculations and identification of account coding to properly manage gross adjustments, provider check processing, provider payments, and accounts receivable related to claims processing and provider agreements to include but not limited to a Stipulation of Settlement. Responsible for supporting the coordination, implementation, and monitoring of system changes including preparing and reviewing system design documents such as Change Orders, Business Requirement Documents, Data Maintenance Requests (DMR), and Reference File Request (RFR). Responsible for reviewing, analyzing, processing, and implementing recommendations from various PROMISe™ claims review audits including but not limited to, NF rate adjustments, Bureau of Hearings and Appeals (BHA), Bureau of Financial Operations (BFO), and QMET and recommending programmatic changes for process improvement within the Division. Provides technical and analytical assistance to all NF and HCBS waiver and program providers and responds to questions and concerns in accordance with all applicable Federal and State Regulations, Waivers, and policies and procedures. Serve as a liaison with other Bureaus within OLTL, Community HealthChoices Managed Care Organizations (MCO), and business partners and identifies potential impacts of program changes for OLTL providers and to support operations. Review, analyze, and monitor all applicable Federal and State Regulations, Waivers, policies and procedures, provider handbooks, and Bulletins to ensure that the Bureau’s operational policies and procedures are implemented accordingly. Reviews and prepares correspondences for the Bureau and Division Director under the Bureau of Fee-for-Service Programs. Communicates and effectively responds to phone calls, emails, and other correspondence from providers, business partners, staff, and other stakeholders. Responsible for providing statistics and reports on the progress of all projects and recovery efforts such as an executive review or analysis of projects assigned. Other duties as assigned. |
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. Independence is exercised for daily responsibilities and routine decision making. Takes initial steps to research and develop a resolution to issues within the level of authority prior to seeking direction from supervisor; determines if requests address guidelines in accordance with the Statement of Policy and applicable Regulations. |
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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. 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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