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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00056540 |
Description Activated On: 6/10/2026 12:06:13 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 position performs complex technical work involving the processing and adjudication of medical and transportation claims for the Chronic Renal Disease Program (CRDP) and providing interpretation and explanation of billing procedures to providers and cardholders. |
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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. Invoice Processing Independently review invoices submitted electronically by CRDP providers for services provided to CRDP cardholders for medical, transportation, and hospital services through the Department’s Core System for electronic billing. This includes the following duties: • Verify provider and recipient eligibility, category of service, third-party liability enrollment, and service dates using electronic database queries, including Department of Health Core System, enrollment contractor database, Department of Human Services (DHS) PROMISe system and eCIS. • Verify Medical Assistance eligibility of cardholders and interpret MA eligibility categories to determine whether explanation of benefits (EOB) must be submitted by provider. • Determine methodology for calculating payment through review of CRDP fee schedule, service codes, and third-party payments. • Interpret EOBs provided by third-party payors to reconcile service codes and determine co-insurance or deductible payment amount • Query DHS PROMISe system to obtain diagnostic related grouping (DRG) payment rates for providers, DRG number and calculation weight. Interpret DRG length of stay to number of days billed by provider and calculate payment amount in accordance with CRDP policies, other third-party insurance payments, DRG number, rate, and weight. • Review accuracy of invoices and attachments submitted by providers and determine whether to correct or reject invoice based on nature of errors. • Assign appropriate tracking code and accounting codes to each claim. • Adjudicate service claims based on verification of accuracy and completeness. • Approve CRDP claims that are adjudicated by other CRDP staff. • Verify dates, service condition, EOBs, and any overrides that were completed. • Approve correct claims or deny claims with errors. • Return denied claims to claims processor to be corrected. • Provide technical assistance to claims processor regarding incorrectly processed claims for the purpose of improving accuracy and operational efficiency. • Review patient share of cost letters for accuracy and verify cardholder information on the letters before mailing them out. • Provide technical assistance in response to providers’ or cardholders’ inquiries or requests related to the status of claims submitted or explanation regarding rejected invoices and invoice submission procedures. Utilizes the DHS's DRG system to calculate hospital payments. This involves entering diagnosis codes, surgical procedure code, if provided, and length of hospital stay. Once a calculated amount is provided by the system, factors any other third-party insurance paid amounts to determine final payment. Enters information into the DRG worksheet and enters information relative to the payment or non-payment of the claim into the Core System. Conducts an independent review of the CRDP Fee Schedule, Explanation of Benefits (EOB) from Medicare and all other third-party insurers, to appropriately calculate the co-insurance and deductible invoiced amounts. Analyzes the invoice to determine if the services are payable under the CRDP. Calculates reimbursement rate to the provider based on the amount paid by the third-party carrier and CRDP fee schedule. Reviews Federal HCFA/UB92 forms to determine whether the diagnoses for the rendered services are reimbursable under the CRDP guidelines. Responsible for creating a general invoice to have claims paid to providers who submitted an invoice for reconsideration to the CRDP administrator. This includes reviewing and verifying provider, service, and payment information for invoices that are not payable through the Core System. Completes invoice form and submit through the Division’s Administrative Officer for payment, ensuring the invoice is signed and approved by the CRDP administrator. Verifies cardholder’s insurance status through the Core System before determining final provider payment for all CRDP invoices. When necessary, confirms the information with the provider, Prime Therapeutics’ Services' system (formerly Magellan Health) or the insurance carrier. Updates or corrects any discrepancy in Core with the cardholder’s insurance information. Notifies Prime Therapeutics of the cardholder’s change of insurance status. Maintains records to monitor, process, and follow up on discrepancies. Processes refunds from providers for the CRDP for invoices that were processed incorrectly or in which another insurance carrier made payment. Upon receipt of refund payment from provider, query Core System to locate original payment. Determines appropriate cardholder service and line item and accounting codes in Core System and enter refund. Coordinates submission of returning payment to Comptroller’s Office for credit to fund. Invoice Approval Approves provider invoices adjudicated by other CRDP staff. This involves a complete review of the CRDP invoices entered into the Core System before they are sent to Comptroller for payment. Verifies the correct DOH payment, provider and client information. Rejects incorrectly paid invoices and advises staff accordingly. Completes the adjudication process by noting on the Core system that the claim(s) are approved. Responsible for maintaining a record of incorrectly processed claims for quality control purposes. Invoices are audited according to the CRDP policies and procedures. • Approves CRDP claims that are adjudicated by other CRDP staff. • Verifies dates, service condition, EOBs, and any overrides that were completed. • Approves correct claims or denies claims with errors. • Returns denied claims to claims processor to be corrected. • Provides technical assistance to claims processor regarding incorrectly processed claims for the purpose of improving accuracy and operational efficiency. Transportation Applications Assists in the processing of CRDP transportation applications. This involves reviewing completed applications for accuracy and service eligibility, assigning service start and end dates, assigning the approved mode of transportation, updating the transportation information in Core, notifying the individual via letter, and notifying the appropriate transportation provider. Participating Provider Agreements (PPAs) Processing Completes PPAs for submission, including sending renewal reminder email to providers, receiving and processing completed agreements from providers, submitting appropriate documentation to the Office of Procurement, and tracking the status of PPAs. Correspondence Prepares and logs correspondence from CRDP providers or clients in regard to the status of an invoice or provider billing issues. Customer Service Independently utilizes various resources such as the Core System, DHS's automated PROMISe system, eCIS and the Department of Aging's automated Prime Therapeutics system to independently answer telephone inquiries received from cardholders and providers pertaining to eligibility periods, status of invoice reimbursements, availability of provider, questions concerning reimbursable or denied services, etc. Makes independent judgements and decisions based on available information in order to respond to cardholder and provider needs. Consults with CRDP Administrator and/or Manager on an as needed basis for unresolved issues. General Completes necessary paperwork to track checks that are not received by providers. Participates in the Bureau's employee driven workgroup, which is specifically designed to discuss and recommend revisions to existing policies or create new procedures relative to Claims Processing activities. Attends educational seminars conducted by DOH, Medicare, and Department of Aging for current policies, procedures, and practices applicable to the CRDP. Identifies processing issues with the Core System. Provides recommended resolution to these issues. Recommends policies and procedures specific to the CRDP for internal processing of invoices. Operates personal computer, photocopy equipment, facsimile machine, calculators, and other small office machines. Opens, stamps, sorts and distributes incoming mail for the CRDP on a rotating basis with other staff. Maintains confidentiality on all sensitive issues and correspondence. Maintains confidentiality of any Protected Health Information (PHI) encountered during the performance of job duties pursuant to the Health Insurance Portability and Accountability Act (HIPAA) which limits the disclosure of this information. Public Health Emergency Response – This position may be given an assignment to support the public health emergency response mission of the Department of Health. Emergency assignments could at times be received with little or no advance notice and may continue for any period of time – ranging from a few hours to several weeks, depending on the nature of the circumstance. The emergency assignments may at times be performed under adverse conditions and may require travel to another site other than the employee’s assigned headquarters for a period of time. Health Equity – Demonstrate awareness of the vulnerable populations the organization serves by identifying, providing, and advocating for resources, services, communication methods, and policies that would help those populations achieve health equity. Performs 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. Individual works directly with providers and cardholders to resolve questions relative to billing issues. This entails advising the provider or cardholder of the corrective action that needs to be taken in order for payment to occur or clarify DOH’s denial of the claim. Must have current and comprehensive knowledge of the Department and Division policies and procedures, eligibility criteria, fee schedule, and service coverage specific to the CRDP. Must also have general knowledge of other services available in the Department of Health, other state agencies (i.e., DHS), as well as PACE, Medicare, MA, and private agencies in order to make appropriate referrals. Independence is exercised for daily/routine responsibilities. Problems and concerns are discussed with the Supervisor. Supervision is received through regular progress meetings and the review of completed work. |
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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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