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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00180289 |
Description Activated On: 8/14/2025 9:03:00 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. The Medical Records Examiner is a registered nurse working in the Bureau's Behavioral Health Review Section. They are responsible for reviewing and evaluating the medical necessity, appropriateness, quality, quantity, and adequacy of medical care and services rendered by behavioral health providers under the Medical Assistance (MA) 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. Identifies discrepancies through the analysis of paid claims, medical records, and other documents to select for review those providers who are not in compliance with Medical Assistance regulations. Prepares case findings, consults with the psychiatrist, recommends the type of administrative sanctions, and prepares the necessary letters to providers. Keeps the Section Supervisor informed of case development and progress. 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. Evaluates the services rendered by conducting record reviews, validation surveys, recipient interviews, peer review meetings, and other applicable review activities in order to detect MA Program abuse and/or potential fraud. Participates in meetings with the Division Director, Section Supervisor, legal counsel, and other agencies 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 to defend review findings. 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, communicate with providers, or to carry out necessary review activities. Performs additional related duties by carrying out miscellaneous assignments 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 and objectives of the Bureau. Uses appropriate judgment and discretion in bringing matters 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: Behavioral health nursing experience preferred. 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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