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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00169474 |
Description Activated On: 5/6/2025 2:45:58 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 professional position is located the Hospital Based Services Section, Division of Program and Provider Compliance, Bureau of Program Integrity (BPI) of Office of Administration (OA). The incumbent is a registered nurse who functions as a case coordinator and is responsible for reviewing and evaluating medical necessity, appropriateness, quality, quantity, and adequacy of medical care and services rendered by providers under or on behalf of the Pennsylvania Medical Assistance Program. The incumbent is responsible for selection of cases based on reports generated by the Fraud and Abuse Detection System as well as tips, complaints and referrals generated by both internal and external stakeholders. |
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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. Identifies discrepancies by analysis and application of data analytics techniques of provider invoices, claims history profiles, itemized bills, computer reports, medical records, diagnosis coding, Medical Assistance documents, referrals, and other information in order to select for review those providers who are not in compliance with Medical Assistance regulations. Makes recommendations for future areas and/or methods of investigation. Prepares case findings, consults with in-house medical staff, recommends the type of administrative sanction, and prepares the necessary letters to providers. Functions as case coordinator for assigned cases by planning and directing review activities in order to complete the review in an efficient and timely manner. Keeps the Section Supervisor informed of case development and progress. Researches, reviews, analyzes, and evaluates the quality and quantity of services rendered by providers by conducting X-ray and/or record reviews, on-site visits, recipient interviews and evaluations, and peer review meetings in order to detect Program abuse and/or potential fraud. Prepares reports by delineating reasons for review, methodology, findings, violations of regulations, and recommendations in order to provide written documentation of the progress of the case, the findings of the review process, and the basis for the Department’s administrative actions. Participates in the evidentiary meetings with the Division Director, Section Supervisor, in-house medical staff, and/or legal counsel by discussing the provider case history, case strategy, and findings in order to recommend sanctions in accordance with the Department’s guidelines, and to prepare for litigation proceedings. Testifies at administrative hearings and/or trials in Commonwealth or Federal Court by appearing as the Department’s witness in order to provide testimony regarding case development or findings, other pertinent information obtained during the review, and chain of custody of evidence. Prepares additional written material in the course of the reviews by writing memoranda, letters, and reports as indicated in order to make case status changes, refer information to other agencies, to communicate with recipients and providers, or to carry out necessary review activities. Responds to complaints for assigned provider types from multiple sources including, but not limited to the MA Provider Compliance Hotline, stakeholder letters, emails, and telephone calls. Investigates and prepares reports and recommendations relating to providers enrolling or re-enrolling in Medical Assistance in response to requests from the Bureau of Fee for Service Provider Enrollment Section. Responds to requests for information from state or federal government agencies or external stakeholders requesting information under the Pennsylvania Right-to-Know Law. Maintains case tracking information and performs both paper and electronic records management on assigned cases in accordance with BPI policies and processes, including, but not limited to adherence to the Health Insurance Portability and Accountability Act (HIPAA). Performs other related duties and special projects as assigned by the Supervisor in order to meet the goals and objectives of the Bureau. |
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. Works independently within established guidelines to meet the goals of objectives of the Bureau. Uses appropriate judgment and discretion in bringing issues to the Section Supervisor for further direction and guidance. |
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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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