R&E Nurse- Med Care Services

Job DescriptionJob Description

Position Purpose:

The incumbent in this position is in the Division of Integrated Care Programs, Bureau of Coordinated and Integrated Services within the Office of Long-Term Living. The individual in this position provides clinical support to the Living Independence for the Elderly (LIFE) Program – known nationally as the PACE – Program of All-Inclusive Care for the Elderly. This is professional work in the review and evaluation of the medical appropriateness, quality, quantity, adequacy, and compensability of medical care and services rendered by LIFE providers. The incumbent in this position is responsible for annual recertifications; clinical and quality review and monitoring; participant complaints and grievances; assisting the OLTL medical director in reviewing discrepancies of clinical eligibility; and providing clinical consultation to LIFE Leads, as necessary, on medical questions and clinical care.

Description of Duties:

Provide professional and clinical consultative and support services to the Division of Integrated Care Programs for the management of the LIFE Program, a managed care program for the frail elderly.

Review disenrollment summaries to ensure appropriate transition of care.

Assist with and review of participant nursing facility admissions and discharges.

Conduct annual LIFE participant recertifications. Thoroughly review documentation submitted by the LIFE provider organizations to make a determination of participants continued clinical eligibility and future re-certification requirements. Document outcome of review in corresponding files and databases. Provide and maintain written notification to LIFE Providers of review decision.

Record and maintain accurate re-certification and nursing facility information of LIFE population. Review monthly/quarterly Participant Activity Reports submitted by the LIFE Providers to ensure accuracy of information.

Develop and create reports as needed related to participant eligibility, census, demographics, nursing facility placement, and re-certification.

Review Annual Quality Management Report from LIFE Providers for quality issues and program performance as it relates to participant outcomes. Provide feedback to LIFE Leads.

Review HPMS Quarterly PACE Monitoring Reports and participate in the quarterly teleconferences with CMS for each LIFE Provider. Provide feedback to LIFE Leads.

Review all Level II unusual incidents submitted by LIFE Providers and participate in the CMS Level II teleconferences to discuss the LIFE Provider’s internal investigation and corrective action plan. Provide feedback and clinical support to LIFE Leads regarding the incident and plan of correction. Maintain documentation of Level II incidents and outcomes.

Serve as point of contact for participant grievances and complaints received by the Department related to the LIFE Program Coordinate with LIFE Leads and provide clinical evaluation and support to resolve participant grievances/complaints, which may include reviewing medical records, contacting and interviewing LIFE participants, family members, and LIFE Center Staff; assisting participants with understanding the Program’s grievance process; and providing direction on filing a grievance with the LIFE Provider.

Review, analyze, draft and develop policies and procedures related to the LIFE Program.

Establish and maintain cooperative and effective working relationships with CMS, other states, provider staff and co-workers in order to discuss operational and clinical issues as they relate to Pennsylvania LIFE programs. Provide supervisor and division director with written and verbal reports and make recommendations as appropriate.

Work with appropriate Bureau, Office, Departmental and Interagency staff assuring collaboration and coordination between these offices/agencies to assure compliance with state and federal requirements, reviewing and modifying existing procedures/forms, and developing procedures regarding eligibility, enrollment/disenrollment, and recertification of participants.

Respond to inquiries about the LIFE Program from the public, providers and associations both verbally and in writing.

Research problems and issues and provide input and consultation in the evaluation of existing requirements and processes to determine effectiveness of program and existing policies. Recommend changes/modifications as appropriate.

Review, analyze, interpret and provide comments on federal regulations and proposed regulations related to LIFE to determine impact on the Department and initiate action to assure compliance.

Be knowledgeable of federal and state rules and regulations and Departmental policies and procedures for Programs of All-Inclusive Care for the Elderly and LIFE.

Draft correspondence related to the LIFE Program and other relevant long-term care programs for signature by Section Chief, Division Director, Bureau Director, Chief of Staff, Deputy Secretary, Secretary, or Governor.

Assist with planning and implementation of pilots or other state-wide new programs in coordinated care/ managed care/ integrated care for long term services and supports. Provides clinical evaluation and assistance across OLTL in support of new and innovative coordinated and integrated care options.

Travel and actively participate in on-site reviews for the LIFE Program, or in conjunction with the planning, initiating and implementation of new coordinated care/managed care/integrated care programs designed by the Department of Human Services.

Incumbent is expected to report, fully support and elaborate on any findings of clinical non-compliance to a judge and jury in a federal and/or state court case regarding the federal PACE model.

Assist with engaging stakeholders in development and planning of new coordinated care/managed care/integrated care projects. Participate in stakeholder meetings as necessary.

Develop and maintain comprehensive understanding of Medical Assistance Program regulations, third party payer information and Federal requirements concerning Home and Community Based Waivers.

Draft clinical components of any necessary audit findings. Review, evaluation and monitor Corrective Action Plans submitted by LIFE providers to ensure state requirements and federal regulations are being met.

Assist the OLTL medical director in reviewing Functional Eligibility Determinations for the LIFE population (and others as needed) when there is a discrepancy between the FED tool and the physician certification form. Makes recommendations to the Medical Director for sign-off.

Participates in formal training programs.

Perform other related duties as assigned.

Decision Making:
The incumbent is empowered to make decisions within established policies, procedures and regulations for the LIFE Program. The incumbent exercises autonomy in making clinical decisions related to participant eligibility, re-certification requirements, and participant care issues.

Licenses, registrations, or certifications:

1. Registered Nurse

Essential Functions:

1.Evaluate/review clinical records

2.Provide professional and clinical consultative and support services

3.Independently manage workload both at the desk and in the field

4.Conduct annual LIFE participant recertification

5.Interpret policies and procedures

6.Access, review and evaluate documents

7.Write correspondence, reports, documents and enter data

8.Travel throughout the Commonwealth and to other states, including areas not served by public transportation.

9.Develop/maintain working relationships

10.Good oral/written communication skills

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

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