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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00173550 |
Description Activated On: 6/18/2025 2:08:11 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 position is located in the Division of Clinical Review (DCR), Bureau of Fee-for-Service Programs (BFFSP), in the Office of Medical Assistance Programs (OMAP), which is responsible for reviewing and monitoring certain services for Medical Assistance (MA) recipients to ensure that medical necessity is evident; that the Place of Service is appropriate; and that all compensable and necessary services are approved for payment in accordance with applicable State and Federal 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 a review by telephone of Prior Authorization requests for home health services, advanced radiology services, proton therapy services, and hyperbaric oxygen services as indicated by the prior authorization indicator on the reference file to ensure the services are medically necessary and compensable under the MA Program. (Meeting daily/monthly volumetric standards established). 2. Performs a pre-admission review of all elective admissions of MA recipients to acute general hospitals, short procedure units, and ambulatory surgical centers to evaluate the appropriate setting for the services, to ensure medical necessity for the services, and to ensure the admission is compensable under the MA Program (Place of Service Review (PSR)). (Meeting daily/monthly volumetric standards established). 3. Reviews and evaluates medical information given by the practitioner or provider to ensure that services are medically necessary in accordance with applicable State and Federal MA laws and regulations. For PSR, ensures that care is certified for payment at the rate of the appropriate setting in accordance with State and Federal laws and regulations. 4. Approves, approves other than as requested, and denies requests or refers the request to a physician consultant to discuss the medical necessity of the requested service, appropriate setting, and/or the compensability of the case. 5. Consults with the physician consultant on cases for which the medical need for the requested services/items is unclear and arranges telephone calls between the physician consultant and the ordering physician for further discussion of the need for the service/item or for further discussion on the appropriate setting for the service. 6. Enters the appropriate data and decision into the computerized system, which generates notification letters to the practitioner, provider, facility, and/or recipient to provide the authorization number for billing purposes, the reason code for denials, and the appeal process. 7.Consults with the medical consultant when a re-evaluation of a case is requested by a practitioner, provider, or facility to reconsider a previously denied, or approved other than as requested service. 8. Interprets MA policies, regulations and procedures to agency or office staff via telephone conversations. Attends workshops, and/or meetings to ensure a working knowledge in these areas. 9. Attends staff meetings for the purpose of information sharing regarding MA policies, regulations, and review procedures. 10. Maintains continuing education through conferences and the reading of medical journals and documents to keep abreast of current trends for treatment of medical conditions to ensure that proper decisions regarding medical necessity and appropriateness of services is met. 11. 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. 12. Responds to inquires/correspondence from recipients, providers, legislators, legal office and other agencies concerning the program in order to explain regulations, operational methods, and administrative procedures and decisions. 13. Files and retains records in accordance with MA regulations and policies. 14. Performs related work as required and special projects as assigned. Purpose and standards are given at the time of each assignment. 15. 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. Each nurse reviewer answers the toll-free lines and/or reviews the written requests for services/items independently. Extra assignments are given verbally or in writing. Work is reviewed by monitoring of the phone lines, monitoring of daily phone printouts, Cold Reports, Quality Control/Assurance audits, 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. N/A 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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