R&E Nurse- Med Care Services (648519)

Job Description

Job Description

Minimum Qualifications :

• Possession of a current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing; or Possession of a non-renewable temporary practice permit issued by the Pennsylvania State Board of Nursing. Resources possessing non-renewable temporary practice permits must obtain licensure as a Registered Nurse within the one-year period as defined by the Pennsylvania State Board of Nursing.
• Proficient writing and basic Computer Skills to include, but not limited to, Microsoft Office Products
• Three years of professional experience with medical assistance (MA), health care services, or human services
• Minimum of three years of recent (within the last five years) professional experience in one or more of the following areas as related to the position need : long term care, acute care setting, behavioral health setting, drug and alcohol setting, managed care, quality management / utilization review or other related clinical experience; or An equivalent combination of experience and training in the field of medical assistance (MA), health care services, human services, long term care, utilization review, or knowledge of home care
• Knowledge of and familiarity with the following would be beneficial : Inter- Qual criteria, ICD-9 CM, and current procedure terminology,
• Ability to use professional judgment in identifying aberrant patterns and determining the appropriate action to be taken following the documentation review.

Description of Duties :

Identifies discrepancies through analysis of computer reports, claims history profiles, medical records, and other Medical Assistance (MA) documents and referrals in order to select for review those providers who are not in compliance with MA regulations.

Functions as 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 Supervisor informed of case development and progress.

Researches, analyzes, and evaluates the quality and quantity of services rendered by providers of outpatient services by conducting X-ray and / or record reviews, on-site visits, recipient interviews and evaluations, and peer review meetings in order to detect Program abuse and / 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 the evidentiary meetings with the Section Supervisor, in-house medical staff and / or 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 memoranda, letters, and reports as indicated in order to make case status changes, refer information to other agencies, to communicate with recipients and providers, or to carry out necessary review activities.

Responds to complaints for assigned provider types from multiple sources including, but not limited to MA Provider Compliance Hotline, OMAPTips web site, letters, e-mail and phone.

Responds to requests for information from other State or Federal Government offices or outside entities.

Maintains case tracking information on assigned cases.

Makes recommendations for changes in policies and procedures related to the work of the Section.

Travels to perform duties as necessary.

Performs other related duties and special projects as assigned by the Supervisor in order to meet the goals and objectives of the Bureau.

Decision Making :

Independent decisions are made on routine assignments according to established guidelines. Uses appropriate judgment and discretion in bringing matters to the Supervisor for further direction and guidance.

Requirements Profile :

Essential Functions :

About Us :

TulaRay partners with clients to create staffing solutions that meet unique organizational needs. Our services are designed to reduce administrative burdens, protect your brand, and improve assignment time-to-fill. We believe that mutually successful client relationships are built on lasting quality and exceptional customer service. We pride ourselves on our uncompromising commitment to high-quality emergency management & healthcare personnel, while ensuring that our clients are taken care of with personalized attention. TulaRay manages total compliance and respectfully supports hundreds of professionals and patient-centered programs.

TulaRay is proud to be an affirmative action employer and is committed to providing equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you have a disability or special need that requires accommodation, please let us know by visiting our website at tularay.com