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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00173153 |
Description Activated On: 8/27/2026 7:37:18 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 Division of Program and Provider Compliance of the Bureau of Program Integrity (BPI). The incumbent is a registered nurse responsible for reviewing and evaluating the medical necessity, appropriateness, quality, quantity, and adequacy of medical care and services rendered to recipients, by providers under the Medical Assistance 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. 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 through analysis of computer reports, claims history profiles, medical records, and other Medical Assistance (MA) documents and referrals in order to select for review those providers or recipients who are not in compliance with MA regulations. 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 Supervisor informed of case development and progress. Researches, analyzes, and evaluates the quality and quantity of services rendered by providers of outpatient services by conducting medical 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 recipients and/or assigned provider types from multiple sources including, but not limited to: MA Provider Compliance Hotline, OMAP Tips web site, letters, e-mail and phone. Responds to requests for information from other State or Federal Government offices or outside entities. Maintains case tracking information on assigned cases. Makes recommendations for changes in policies and procedures related to the work of the Section. Travels to perform duties as necessary. 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. Independent decisions are made on routine assignments according to established guidelines. Uses appropriate judgment and discretion in bringing matters to the 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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