Position Description

Commonwealth of Pennsylvania
POSITION DESCRIPTION FOR JOB POSTING
Position Number: 00109098	Description Activated On: 1/15/2026 11:42:58 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 located in the Department of Human Services, Office of Medical Assistance Programs, Bureau of Policy, Analysis, and Planning. It is professional work in the review and evaluation of procedure coding including the Health Care Common Procedural Coding System (HCPCS), Current Procedural Terminology (CPT), Current Dental Terminology (CDT) and other coding set and editing information related to the Medical Assistance (MA) Fee Schedules and claims processing system.

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.

An employee in this job is responsible for the review, evaluation and implementation of coding set updates, related systems enhancements, current processes and implementation of recommended process improvements. Work involves the analysis and evaluation of information submitted by MA service providers, insurers, associations, the Federal Medicaid Agency and other applicable sources, as well as claims, encounters and related information in order to make professional judgments regarding MA Program Fee Schedule procedural coding and systems programming. Work may include serving as a team leader on reviews and coordinating the review process. Employees also provide advisory and consultative support to MA policy and other DHS staff, in order to improve the services or administrative procedures in support of the MA Program.

Work is performed under the supervision of MFRE Supervisor and is reviewed through meetings and reports.

Compiles procedure coding information and code sets, clinical and other documentation for the preparation of reports, code set updates, and project plans.

Collaborates with MA policy staff in the development of code set updates, related communications, and provider bulletins.

Participates in management workgroups and project teams.

Possess history of coding knowledge and claims review in addition to utilization review knowledge.

Knowledge of the more common medical diagnoses and the associated treatments and services provided in relation to these diagnoses.

Knowledge of Federal and State rules and regulations and Departmental policies and procedures as related to the Medicaid and MA Program.

Ability to express ideas effectively, orally, and in writing.

Assignments will consist of a combination of on-going process responsibilities, standing work group participation and time limited projects related to the management and operations of all aspects of the Pennsylvania Medicaid program, including but not limited to:

Evaluation and implementation of system enhancements for CMS compliance, provider inquiry and medical review;

Evaluation of currents processes and implementation of recommended process improvements;

Consult with staff within Bureau of Policy, Analysis, and Planning (BPAP), Office of Mental Health and Substance Abuse (OMHSAS), and Bureau of Fee For Service Programs (BFFSP) to outline major operational issues and develop resolutions based on sound data analysis;
Follow up with Bureau of Data Claims Management (BDCM) if necessary in order to implement, develop, or correct the issues above if the solution involves system changes;

Act as liaison between the Department of Human Services and external stakeholders (individuals and/or groups);

Assist in determining if any changes should be made to criteria or regulations to better serve their clients;

Learn and be a resource for how claims process through the PROMISe system;

Assist with coding and procedure code groupings;

Provide operational input for claims processing decisions;

Reviews clinical research and information regarding advancements in health care and related impacts on procedural coding;

Reviews a variety of paid claims statistical reports to determine specific areas for further review based upon trends in diagnosis, treatments, and prescriptions, as well as other possible indicators and participates in the development of these reports;

Discusses potential code set actions and questionable review cases with Departmental Physician Consultants as necessary;

In collaboration with MA Policy staff, communicates MA policies, regulations, and procedures to providers and other parties in order to address inquiries;

Participates in the development of new and/or revisions to existing MA policies and regulations. This also includes reviewing the MA Bulletins prior to the review process to ensure that the information matches the intent and the anticipated system work that will be sent to Bureau of Data Claims Management (BDCM;

Provides consultation and technical assistance to MA Policy, operations and systems staff, Medical Directors, other DHS staff, and health care providers when appropriate;

Reviews claims related to authorization of payment for covered services, when appropriate;

Evaluates potential misconduct on the part of MA Program service providers and/or beneficiaries and recommends the appropriate administrative action or referral to the appropriate legal entity for action;

Provides and evaluates the information that will update current MA policy as well as specific procedure code information to update the MA Fee Schedule in response to the Public Health Emergency (PHE). This will also include the evaluation and consideration of processes needed to update the system and code set after the Public Health Emergency (PHE);

Performs 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.

Independently evaluate, update and maintain the procedural coding sets that comprise the MA Program Fee Schedule through annual and interim updates.

Independently support current system limits and be able to represent the unit while attending meetings on topics that match either past clinical experiences or ones that have been assigned as a representative of the Reference File Unit. This would include advising current medical trends, safe practices, and acknowledging concerns or issues.

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

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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.

1.	Knowledge of procedure coding such as HCPCS, CPT, CDT and ICD-10 CM and ICD-10 PCS related to Medical Assistance (MA).
2.	Knowledge of MA policies and regulations.
3.	Communicates effectively, verbal and written.
4.	Maintains effective work relationships.
5.	Operates various office equipment.
6.	Comprehends and applies rules, regulations and policies.
7.	Completes assignments in accordance with established procedures.
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