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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00155098 |
Description Activated On: 1/5/2026 3:34:44 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. Evaluates the appropriateness, reasonableness, and compensability of medical treatment and services provided to individuals covered by the State Workers’ Insurance Fund (SWIF) in accordance with the Pennsylvania Workers' Compensation Act. Provides clinical guidance and recommends appropriate administrative action based on professional medical judgments. |
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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. Conducts utilization reviews. Evaluates medical information, records, and reports to assess the necessity and appropriateness of care and services provided to SWIF covered individuals. Assesses care/treatment plans; provides authorization for services, medications, or durable medical equipment. Verifies applicable International Classification of Disease (ICD) and Current Procedural Terminology (CPT) codes associated with claims; determines which diagnoses are related to the work injury. Reviews medical bills to evaluate compensability of services and appropriate payment amounts in accordance with SWIF coverage terms and the Pennsylvania Workers’ Compensation Act. Monitors medical management reports and nursing care plans; provides assistance and direction to field office staff as needed. Interacts with other SWIF divisions (such as claims services, legal, fraud) and external organizations (such as pharmacy benefit managers, contractors, third party administrators). Uses standard office applications and SWIF specific systems, such as the Workers’ Compensation Automation and Integration System (WCAIS). Performs related duties and 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. Determines appropriateness, reasonableness, and compensability of medical treatment and services. Decides whether diagnoses and treatments are related to a work injury or occupational disease. Authorizes reimbursement for services, medications, or equipment. |
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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: Current active RN license without restriction. Case Management Certification or workers compensation experience helpful but not required. 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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