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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00203389 |
Description Activated On: 9/25/2025 1:25:06 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 provides professional nursing support within a section of the Health Care Services Review Division (division), Bureau of Workers’ Compensation (bureau) to ensure operations are maintained within the guidelines of the Pennsylvania Workers’ Compensation Act (Act) and Medical Cost Containment (MCC) Rules 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. Under minimal supervision, the professional will demonstrate leadership and perform the following functions: Utilizes the Workers’ Compensation Automation and Integration System (WCAIS) daily to complete assigned tasks and meet the operational needs of the division. Reviews application requests for medical fee (MF) reviews of contested amount and or timeliness of medical payments for services rendered to injured workers. Examines and evaluates medical documents/reports, medical bills, Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), legal documents, compensation forms, insurance forms, decisions, etc. as part of the statutorily required investigation to determine whether fees paid to health care providers are of the correct amount and or paid within the statutorily required time frame. Prepares appropriate documents and correspondence to communicate administrative decisions to all interested parties including health care providers, insurers, self-insureds, and employers etc. Updates and maintains information regarding the WC medical fee schedules, reimbursement guidelines and provides general resource information to medical providers, insurance carriers and employers etc. Coordinates the medical treatment/utilization review (UR) process that includes providing consultation and technical assistance to insurance companies, attorneys, injured workers, and health care providers who are parties to requests for utilization reviews filed with the bureau. Evaluates requests for UR for conformance with the MCC Rules and Regulations and provides verbal or written responses to persons filing such requests. Provides consultation and technical assistance to Utilization Review Organizations (URO) engaged in performing URs of medical treatment rendered by or planned by health care providers who are treating injured workers. Evaluates UR determinations rendered by a URO for compliance with the Act and the MCC Rules and Regulations. This quality improvement effort involves providing written and oral communication with the URO to ensure the appropriate corrective action is taken on future determinations. Monitors and evaluates the overall performance of each URO in rendering UR determinations and makes recommendations to supervisor for training, suspension, or termination of the URO as appropriate. This includes but may not be limited to, developing, and maintaining data on the URO to include timeliness of determinations, quality of reports and appropriately licensed reviewers. Conducts scheduled and unscheduled quality assurance virtual and onsite URO audits. This includes but may not be limited to, review of URO case files to evaluate the URO’s compliance with regulations and established bureau criteria and, to validate the quality of UR determinations based on a random review of case files. Advises the URO of areas needing immediate corrective action. Prepares a written report of the audit findings with recommendations for correcting deficiencies. Evaluates applications for reauthorizations of UROs requesting certification to operate as a URO under the Act; evaluates the qualifications of the URO including the medical experiences and training of personnel, past performance, and its ability to comply with criteria established by the bureau for URO certification; prepares reports of deficiencies in applications and makes written recommendations on the approval or denial of application to the section supervisor. Participates, as needed, in the hearing process providing explanation and justification of medical fee review findings or URO suspensions or reauthorization denials. Participates, as needed, in planning and conducting training sessions for peers, repricers, insurers, employers, UROs, medical providers etc. Participates in WCAIS and other testing scenarios for MFRE roles as requested by the section supervisor. Participates in quality assurance and improvement activities as assigned. Completes various other tasks and duties assigned. |
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. The nurse professional will be capable of high-level independent decision making to determine amount of medical fees owed and or timeliness of payment. The decisions have a direct impact on payment of medical treatment for injured workers and are subject to appeal to a medical fee review Hearing Officer and Commonwealth Court. The nurse professional also approves or disapproves assignment of utilization review requests to a URO for its determination and approves or disapproves UROs requesting reauthorization certification. |
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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: License to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing 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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