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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00280080 |
Description Activated On: 7/18/2025 11:19:42 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 in the Division of Program and Provider Compliance, Bureau of Program Integrity (BPI), Office of Administration (OA). The incumbent holds a current, valid Pennsylvania Registered Nurse license and is responsible for reviewing records, documents and the claims submitted by enrolled Medical Assistance (MA) providers. The incumbent will review services provided to eligible beneficiaries of the MA Program to evaluate and determine if the services were medically necessary and billed in accordance with MA Regulations and other State and Federal requirements. |
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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 by analysis of provider invoices, claims history, medical records and other MA documents and referrals in order to select for review those providers who are not in compliance with MA regulations. Functions as a 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 Section Supervisor informed of case development and progress. Research providers to ensure credentials/licenses are valid and to determine if the provider/entity is eligible to provide services and has not been precluded or excluded from Federal or State participation. Research, analyze and evaluate the quality and quantity of services rendered by providers by conducting record reviews and/or on-site visits in order to detect Program waste and abuse 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 evidentiary meetings with the Division Director, Section Supervisor, and 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 memorandums, letters and reports as indicated in order to make case status changes, refer information to other agencies, to communicate with providers, or to carry out necessary review activities. Responds to complaints for assigned provider types from multiple sources, including but not limited to the MA Provider Compliance Hotline, stakeholder letters, emails, and telephone calls. Responds to requests for information from State or Federal government agencies or external stakeholders requesting information under the Pennsylvania Right-to-Know Law. Maintains case tracking information and performs both paper and electronic records management on assigned cases in accordance with BPI policies and procedures, including, but not limited to adherence to the Health Insurance Portability and Accountability Act (HIPAA). Teleworks as eligible and authorized by Department policy. Performs additional related duties by carrying out miscellaneous assignments or special projects 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 in accordance with established guidelines and to meet the mission of the Bureau. Appropriate judgment and discretion are used 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: Licenses, registrations, or certifications: 1. Registered Nurse 2. N/A 3. N/A 4. N/A 5. N/A 6. 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.
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