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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00172819 |
Description Activated On: 4/20/2026 10:30:15 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 in the Inpatient Clinical Review Section, located in the Division of Clinical Review(DCR), Bureau of Fee-for-Service Programs(BFFSP), in the Office of Medical Assistance(MA). Inpatient Clinical Review Section is responsible for performing an admission review for Medical Assistance recipients for all urgent and emergency admissions to acute general hospitals and short procedure units; elective admissions to medical rehabilitation hospitals; for medical necessity, appropriate setting and compensability of services in accordance with applicable State and Federal Medical Assistance (MA) laws and regulations. |
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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. 1. Performs an admission review of all urgent and emergency admissions to acute general hospitals and short procedure units; elective admissions to medical rehabilitation hospitals; to evaluate the medical necessity and the appropriate setting for the services to ensure that the admission is medically necessary and compensable under the MA Program. (Meeting daily/monthly volumetric standards as established.) 2. Reviews and evaluates medical information given by the facility during the scheduled call or via the electronic review form to assure that care is certified for payment at the rate for the appropriate setting and is in accordance with applicable State and Federal MA laws and regulations. 3. Certifies urgent and emergency admissions and/or medical rehab admissions requests or refers the request to the physician consultant for medical necessity, the appropriate setting, and/or compensability of the case. 4. Consults with the physician consultant on cases for which the medical need for the requested setting is unclear. 5. When a teleconference (a future phone call between the department’s physician consultant and the hospital’s physician) is requested, forwards the necessary information to the scheduler and informs the provider as to their responsibilities in scheduling it. 6. Enters the appropriate decision into the computer and generates the notification of decision letters to the facility and the practitioner which provides them with the necessary decision and authorization number needed for billing purposes or appeal process. 7. Interprets MA utilization review policies, regulations, and procedures to hospital staff via telephone conversations, workshops, and/or meetings to ensure a working knowledge in these areas. 8. Attends staff meetings for the purpose of information sharing regarding MA policies and regulations, procedures, and new processes. 9. Maintains continuing education through conferences and the reading of medical journals, regulations, and documents to keep abreast of current trends for treatment of medical conditions to ensure that proper decisions are made regarding medical necessity and appropriateness of services provided to Medical Assistance recipients. 10. Relieves in other sections as required in order to maintain all program functions. Updates in the process will be scheduled as necessary to ensure a working knowledge in the different areas. 11. Responds, if requested, to any inquiries/correspondence from providers, legislators, legal office and other agencies concerning the department’s program in order to explain regulations, operational methods, and administrative procedures and decisions. 12. Performs other related work as required and special projects as assigned. Purpose and standards are given at the time of each assignment. 13. Assists with training new staff and cross training of existing staff as requested per supervisor. 14. This position has been designated as a Telework Eligible Position. Your supervisor will determine if/when you may be eligible to participate in a telework arrangement. Telework is not an employee right or guaranteed employee benefit, and is at the sole discretion of, and subject to, the prior written approval of management. |
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. Interprets MA utilization review policies, regulations and procedures to hospital staff via telephone conversations, workshops or meetings to ensure a working knowledge in these areas. Each nurse independently reviews requests for services to ensure eligibility and to determine if medical necessity is met, for the requested services; or if a referral to a physician consultant is necessary. Extra assignments are given verbally or in writing. Work is reviewed by monitoring of Cold Reports, Quality Assurance checks and conferences with the supervisor. |
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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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