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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50328093 |
Description Activated On: 6/15/2026 12:31:13 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. The incumbent provides professional work of a highly independent and administratively specialized nature in order to maintain ODP specific logic found in the PROMISe Reference File, claim ESCs (Error Status Codes), provides assistance with resolving billing/reimbursement issues for ODP providers. 75% of incumbent's work week is dedicated to receiving calls via ODP's Claims Resolution Inquiry phone line and/or ODP’s Claims Resolution e-mail account. |
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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. Provides training, technical assistance and guidance to providers in the ODP program who are experiencing issues and/or receiving errors with claims submitted through PROMISe. ODP Claims Resolution staff communicate with providers via a dedicated inquiry phone line and e-mail resource account. This position receives calls, fields questions, troubleshoots technical issues preventing accurate payment for claims submitted, researches issues and provides resolution to provider inquiries. Researches complex system logic between the PROMISe billing system, HCSIS authorization system, and Electronic Visit Verification (EVV) system to ensure payment complies with all Medical Assistance Federal and State Regulations and ODP Policy. Follows up with stakeholders as required. Maintains a general understanding of PROMISe claims processing system from claims submission, claim adjudication, claims plan validation, financial cycle and generation of the remittance advice. This includes data entry guidance, edits/audits and the interaction and relationship of the different PROMISe subsystems as they apply to claims which includes the recipient, reference, provider and financial subsystems. Also understands the relationship and logic associated with claims and plan validation that occurs in the Home and Community Based Services Information System (HCSIS). Researches and prepares recommendations for resolution of problems/issues identified through the PROMISe claims processing system. Identifies and resolves issues identified within the Base program, Consolidated, P/FDS, and Community Living waivers relating to claims processing. Requests updates to the various enterprise systems as needed. Researches and resolves discrepancies in HCSIS and the Client Information System (CIS) relating to ODP claims. Reviews timely filing exception requests (180 and 365 days) and makes final determination on claims payment status based on State Regulations. Represents ODP at provider hearings related to determinations made regarding ODP's timely filing exception process. Reviews Edit/Audit fiscal year limitation exceptions requested by ODP Regional Staff and maintains database for accurate suspended claim processing. Researches and identifies other problem areas in the PROMISe Reference File. Completes problem requests assigned by the unit supervisor which require extensive research. This involves a working knowledge of PROMISe, HCSIS and EVV operations. Reviews and analyzes proposed policy, newly issued policy, and all informational material to ensure that the procedure codes, diagnosis records, edits and audits (ESCs) and resolutions used by ODP are in compliance with State and Federal Regulations and ODP Policy. Researches, analyzes, and identifies changes and/or solutions to program operation problems to ensure compliance and enforcement of regulations and policy. Serves as a subject matter expert for other ODP staff by answering and explaining questions regarding ESCs and ESC resolution procedures. Develops and maintains various informational documents which are utilized by ODP employees. Prepares correspondence as necessary. Prepares oral and/or written reports. Assists as needed in researching and resolving HCSIS issues. Prepares and submits changes for the Reference File. Assists with the review and processing of suspended claims. Conducts business meetings including devising an agenda, leading discussions, documenting follow-up items, and preparing file notes for distribution to attendees. Provides input to changes in operational processes due to system changes and implementations. Represents ODP at internal and external meetings and conferences. Performs other related duties as required. |
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. During the course of researching problems with PROMISe and/or HCSIS, the incumbent makes independent decisions regarding how the problem can be corrected. A description of the problem and the planned course of action is reported to the supervisor. During the course of researching ESC resolution procedures, the incumbent makes decisions regarding how the resolution procedure needs to be implemented and prepares a formal response/document for approval of 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. N/A 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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