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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50703061 |
Description Activated On: 2/6/2026 9:24:02 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 employee in this position reports to the Clinical Review Team (CRT) Section Chief, Quality Assurance Division within the Bureau of Quality Assurance and Program Analytics, Office of Long-Term Living (OLTL), Department of Human Services (DHS). Review and evaluate Medical Director Reviews (MDR) related to Functional Eligibility Determinations (FED) discrepancies. Conduct clinical reviews on Physical Health (PH), Pharmacy (RX) and Home and Community Based (HCBS) denials submitted by the Community HealthChoices (CHC) Managed Care Organizations (MCO). Review and evaluate the QMUM-008 – Licensed Proprietary Products (LPP) Annual Report submitted by the CHC-MCOs as directed by the OLTL Medical Director. Assist with reviewing Preventable Serious Adverse Events (PSAE) to ensure NFs report PSAEs as required. Conduct case reviews of Community HealthChoices (CHC) Managed Care Organizations (MCO) PSAEs being submitted on OPS-019 as needed. Review and evaluate medical information submitted by the nursing facilities (NF's) that request participation and acceptance in the Durable Medical Equipment (DME) for Nursing Facility Resident Program and Ventilator Program. Review and evaluate Prior Authorization Review Process (PARP) Policies submitted by the CHC-MCOs as directed by the OLTL Medical Director. Review and complete assigned Systemic Monitoring Access Retrieval Technology (SMART) standards in Medicaid Enterprise Monitoring Module (MEMM). |
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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. Assists with reviewing and evaluating MDRs related to FED discrepancies between the FED and Physician Certification or MA 51. Acquire knowledge related to the determination of Nursing Facility Clinically Eligible (NFCE) and Nursing Facility Clinically Ineligible (NFI). This includes reviewing participant health information and collecting all necessary information required for review. Assists with the development and updating of training materials for new versions of InterRAI and FED used by Service Coordinators (SCs). This includes reviewing policy and system changes, incorporating updated requirements into training content, and supporting the delivery of guidance to ensure SCs understand proper completion, documentation standards, and compliance expectation related to InterRAI and FED. Assists with clinical reviews related to PH, RX and HCBS denials submitted by CHC-MCOs. Review of denial notices includes determining if an appropriate denial notice was used, if the denial was handled within the required timeframes, was the denial appropriately denied given the provided justification and if the appropriate appeal rights was included in the denial notice. Assist with reviewing and evaluating the QMUM-008 – LPP Annual Report submitted by the CHC-MCOs. CHC-MCOs must maintain current and, as applicable, clinically, and operationally appropriate LPPs according to nationally recognized medical standards of care. This report is a submission of all LPPs utilized by each CHC-MCO. Assists with reviewing PSAE. In coordination with DOH this position monitors and ensures nursing facilities report PSAEs as required. This includes reviewing reports, determining the type of event, and collecting all necessary information required for review. This position reviews PSAEs with the OLTL Medical Director as necessary. Conduct case reviews of CHC-MCO’s PSAEs being submitted on OPS-019. Assist CHC-MCOs with case follow-ups and completion of OPS-19. Review and evaluate Prior Authorization Review Policies (PARP) submitted by the CHC-MCOs to determine compliance with CHC-MCO Agreement requirements and alignment with industry standards. Maintain current knowledge of applicable medical policies and clinical protocols and collaborate with the OLTL Medical Director ass needed during the review process. Assist with reviewing and evaluating SMART standards assigned to the CRT in MEMM. Review of the standards includes determining if the CHC-MCOs are following requirements set forth in the CHC Agreement. The position reviews SMART standards with the CRT Section Chief as needed. Assist with the development of monitoring tools to support the CRT. The employee is required to have working knowledge of basic personal computer analysis tools such as Microsoft Excel and server-based tools such as Docushare, Provider Reimbursement and Operations Management Information System (PROMISe), Nursing Home Information System (NIS), Pennsylvania Individualized Assessments System (PIA), Provider Enrollment Automation Project (PEAP), Client Information System (CIS), and MEMM. Participate in meetings related to the CHC-MCOs, HCBS, NF and Quality Management programs within OLTL. Write and revise internal protocols for Quality Assurance – CRT. Participate in the development of new and/or revisions to existing HCBS policies. Provide technical assistance and training to provider staff and OLTL staff as needed. Participate in required training programs. Coordinate meetings, as necessary with CRT and Medical Directors when needed to collaborate on policy and other duties required in the course of the job description. Perform other related job duties. |
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. Provide interpretation of policies, procedures and guidelines for the MA Program. Develop and evaluate programs for statewide implementation and monitor the implementation of new or revised regulations and program procedures. Develop and maintain regulations, procedures and forms for MA programs and develop written procedures and design forms to implement program changes. Write and review proposed operating manuals and informal material assuring consistency and conformity to MA program objectives and policies. Coordinate MA program operations with other offices to prevent overlapping and duplication; assure adequate coverage and promote utilization of existing departmental resources and services. Assists with clinical reviews related to PH, RX and HCBS denials submitted by CHC-MCOs. Denial reviews include the review of 6 elements: report documentation, supporting documentation, timeframes, medical necessity, evidence of physician/dentist review and readability of denial notice. Establish and maintain cooperative and effective relationships with CHC-MCOs in order to discuss clinical reviews related to denial notices. Develop plans for program management by establishing objectives, action steps, completion dates, scope and program parameters, and coordinate the collection of data from other sections and divisions in the Office of Medical Assistance Programs and other state agencies. Review medical records and FED using the Department approved criteria and confer with Medical Director to determine if participant is NFCE or NFI. Perform other related functions as assigned. |
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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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