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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00093145 |
Description Activated On: 12/29/2025 10:26:59 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 serves as professional staff in the Bureau of Managed Care Operations (BMCO) and reports to the Clinical Operations Supervisor in the Clinical Operations Section of the Division of Quality and Special Needs Coordination (DQSNC). This position represents the DQSNC and has clinical responsibility for ongoing monitoring and evaluation of the day-to-day Quality Management, Utilization Management, and Quality Improvement (QM/UM/QI) operations of the assigned HealthChoices Managed Care Organization(s) (MCO). This person serves as and provides clinical expertise within a multidisciplinary contract management monitoring team as designated by the Division Director of DQSNC and Bureau Director of BMCO. In addition, this person provides advisory and consultative services with other bureaus within the Department of Human Services (DHS), other state agencies and external stakeholders as necessary to ensure compliance with quality management, utilization management, and quality improvement requirements for the HealthChoices Program. |
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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. Monitor assigned PH-MCO contractor(s) performance to evaluate compliance with the HealthChoices Agreement requirements and applicable State and Federal regulations in the areas of Quality Management, Utilization Management, and Quality Improvement (QM/UM/QI) for the Medical Assistance Program. Requires working knowledge of the HealthChoices Agreement and any State regulations, Federal regulations, Medical Assistance Bulletins, and HealthChoices Operations Memos that are applicable. Review PH-MCO(s) Licensed Proprietary Products used in making medical necessity determination to ensure medical necessity decision making tools do not conflict with the HealthChoices Agreement, State and Federal regulations, the PA code, Medical Assistance Bulletins and HealthChoices memos. Review and utilize data such as Healthcare Effectiveness Data and Information Set (HEDIS®) and Performance Improvement Projects (PIP’s) to make determinations on quality management of PH-MCO(s) Health Choices programs. Design, create and analyze quality improvement project(s), program(s) and/or report(s) for the HealthChoices Agreement to monitor PH-MCO quality and utilization management programs. rovide Clinical related support to the Quality Accountability Section to monitor the PH-MCO Community Based Care Management and Maternal Home Visiting Programs and the Rapid Cycle Improvement (RCI) Initiatives as needed. Manage the denial review process for assigned PH-MCO(s) to ensure that utilization management practices are permissible and that services are not inappropriately denied due to budgetary constraints. Requires sampling and analysis of denial notices; Entering findings of denial record reviews into a clinical spreadsheet that is used to identify and track PH-MCO denial discrepancies and inconsistencies; and Discussing the PH-MCO(s) audit results via a quarterly conference call and implement improvement plans to correct discrepancies. In addition, participate in training sessions for PH-MCO(s) on the denial process, as needed. Review assigned PH-MCO(s) QM/UM report which includes the denial service logs and records for documentation supporting evidence of interaction with the prescriber, consistency with the HealthChoices definition of medical necessity, timeliness of member notification, and initiation/completion of any associated grievance or appeal. Review assigned PH-MCO(s) quality management, utilization management, and quality improvement policies and procedures and the manner in which they are implemented. Review of the assigned PH-MCO(s) QM/UM/QI reports submissions that includes but is not limited to PH-MCO annual and quarterly work plan, annual program description, annual policies and procedures and annual program evaluation. Review and analyze other annual, monthly, quarterly and semi-annual reports submitted by assigned PH-MCO(s). Participate in the routing and review of the assigned PH-MCO(s) prior authorization policies and procedures submitted to the Prior Authorization Review Panel (PARP) process. Develop, if needed, Quality Improvement projects, programs or reports for the HealthChoices Agreement to monitor the management, implementation and utilization of the managed care contractor. Provide clinical expertise as a member of the multidisciplinary contract management oversight team. This includes: participation in Quarterly Quality Review Meetings, traveling onsite to PH-MCO(s) offices or participating in virtual onsite reviews, and serving in a clinical capacity for the Division of Monitoring and Compliance. Provide Clinical support for the Enhanced Member Supports Unit (EMSU) and Complaints, Grievance, and Fair Hearing (CGFH) Unit within DQSNC as needed. Prepare internal reports which describe and evaluate the PH-MCO’s performance and identify the need for corrective actions. Participate in a multidisciplinary contract management team. Activities may include but not be limited to: Provide clinical expertise as member of the assigned PH-MCO(s) Contract Management team. Make recommendations for corrective action to the Contract Manager of the contract management team as needed. Monitor the implementation of corrective action plans, if implemented. Enter results of QM/UM/QI monitoring activities into the SMART database which provides results of the assigned PH-MCO(s) performance over the designated contract monitoring year. Ensures that the information entered into the SMART database are complete and provide a basis for the identified outcome for a particular SMART standard. Is proficient in the use of Docushare which is an on-line repository of documents that are provided by the assigned PH-MCO(s) to support requirements in the HealthChoices Agreement for QM/UM QI monitoring. Is proficient in the use of SharePoint and other software, such as Microsoft Office and Adobe, that is used to review, monitor and analyze information used in monitoring the PH-MCOs. Perform research and analysis and draft internal reports on issues and programs related to the QM/UM/QI process. Participate in workgroups or meetings with other state agencies on QM/UM/QI initiatives related to the HealthChoices agreement. Participate in virtual and on-site monitoring visits, as needed. Perform other related duties 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. Research, resolve and/or refer day-to-day clinical operations issues related to QM/UM/QI functions that are consistent with professional experience and knowledge of Department goals and objectives. |
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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. Registered Nurse 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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