Position Description

Commonwealth of Pennsylvania
POSITION DESCRIPTION FOR JOB POSTING
Position Number: 00215762	Description Activated On: 5/27/2026 1:14:10 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 in the Referral and Program Support Section of the Division of Provider Review in the Bureau of Program Integrity. The incumbent performs independent work involving the planning, organizing, analyses, investigation and reporting for the detection of fraud, waste and abuse. This includes triage and preliminary review of incoming referrals/complaints, analyses of data/claim/encounters and review of providers’ records, to determine appropriate charges, billing and compliance with other state and federal requirements.

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/encounters, computer reports, medical/financial records and other information.

Functions as case coordinator for assigned cases by planning and directing review activities to complete reviews in an efficient and timely manner.

Evaluates the type, scope, amount, duration and frequency of authorized services, to include an evaluation of the documentation to support the service billed.

Prepares case findings, consults with in-house medical staff, recommends the type of administrative sanction, and prepares the necessary letters to providers.

Prepares referrals for supervisor review to be sent to internal and external stakeholders, including the Office of Attorney General Medicaid Fraud Control Section for allegations of fraud or abuse.

Maintains case tracking information and performs both paper and electronic records management on assigned cases in accordance with BPI policies and processes.

Participates in meetings with the Division Director, Section Supervisor, Legal Counsel and other agencies/entities as part of the Bureau’s process.

Testifies at administrative hearings and/or trials in Commonwealth or Federal court by appearing as the Department’s witness to provide testimony regarding case development or findings, other pertinent information obtained during the review and chain of custody of evidence.

Keeps the Section Supervisor informed of case development and progress.

Assists in the development of new algorithms for fee-for-service claims and managed care encounters to proactively identify fraud, waste and abuse in the Medical Assistance (MA) Program

Researches and analyzes MA program data and regulations to identify possible program vulnerabilities and provides recommendation(s)to the Section Supervisor.

Acts as a staff liaison for Bureau PI vendor contracts, including but not limited to, data and contract oversight support.

Acts as a technical staff liaison for Bureau vendor programs including claims and data.

Acts as a staff liaison for updates and changes in the current and future MMIS program to ensure PI activities are preserved.

Works to design, develop, implement, and maintain additional new systems to enhance workflow, productivity and encourage efficiencies on a Bureau-wide basis.

Develops policies and procedures, program proposals, specifications and evaluation criteria for enhanced program oversight.

Performs additional related duties by carrying out miscellaneous assignments or special projects 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.

Work is performed with independent judgement and decision making under the general supervision of the Section Supervisor.

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.   N/A

2.   N/A

3.   N/A

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5.   N/A

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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.

1.	Analyze, comprehend and apply knowledge of laws, regulations and policies governing the agency.
2.	Review and interpret program and fiscal data.
3.	Complete assignments in accordance with established procedures.
4.	Prepare correspondence and reports.
5.	Plan and organize work to achieve desired results.
6.	Communicate effectively (both verbal and written).
7.	Establish and maintain effective working relationships.
8.	Exercise judgement, discretion and confidentiality throughout the review process.
9.	Operate various office equipment to perform duties.
10.	Travel to attend trainings/meetings/on-site visits to effectively perform duties.