R&E Nurse- Med Care Services

4 weeks ago

Harrisburg, United States TulaRay Full time
Job DescriptionJob 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.

Role Description:

Identifies discrepancies through the analysis of paid claims, itemized bills, data available in the Pennsylvania Provider Reimbursement and Operations Management Information System (PA PROMISe), the Client Information System (CIS), and computer reports obtained from the Fraud Abuse Detection System (FADS). This includes but is not limited to analysis of paid claims for patterns identified with high-cost, high-volume providers, and potential cases for review.

Selects, reviews, analyzes and evaluates cases retrospectively to monitor compliance with State and Federal Regulations. Services are monitored for medical necessity and quality of care. Verifying that services ordered were rendered, and all rendered services were ordered and are appropriate.

Analyzes for up coding, duplicate billing, and unbundling of billed services that have been inappropriately billed to MA by non-hospice providers. Uses the ICD-9-CM and ICD-10-CM diagnosis and procedure manuals, coding clinics, CPT and HCPCS manuals, provider handbooks, and other related manuals to determine that the paid claim was billed appropriately.

Prepares case findings, consults with physician consultants, prepares preliminary and final letters to providers, researches and utilizes appropriate MA regulations, MA bulletins, Managed Care Organization (MCO) provider contracts and payment policies, and Federal Regulations.

Keeps the section supervisor informed of case development and progress as well as keeps the Bureau’s Case Tracking system updated for each active case. Prepares replies to correspondence under the direction of the section’s supervisor.

Functions as case coordinator for assigned cases by planning and conducting retrospective review activities to complete the cases in an efficient/timely manner.

Performs in-house and on-site reviews to verify/assess the medical care rendered by providers, including the review of medical and fiscal records

Coordinates, schedules and participates in teleconferences and meetings when requested by the providers, to include physician consultants, DPW legal counsel, and providers, as applicable, to discuss review processes/case findings.

Participates in evidentiary meetings with the Section Supervisor/Division Director, in-house medical staff, legal counsel, MCO staff, or other offices/agencies by discussing the provider case history, case strategy, and findings to recommend sanctions in accordance with Department guidelines/applicable contracts and to prepare for litigation proceedings.

Prepares written material in the course of the reviews by writing memoranda, letters, and reports as indicated in order to provide case findings and violations, refer information to other agencies, to communicate with recipients and providers, or to carry out necessary review activities.

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

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

Prepares paperwork as required to facilitate restitution via the claims adjustment or gross adjustment processes.

Essential Functions:

1. Knowledge/use of Microsoft Office products and training in Excel

2. Communicates effectively, verbal/written

3. Prepares correspondence and reports

4. Testifies at legal proceedings

5. Comprehends & applies rules/regulations

6. Completes assignments per procedures

7. Establishes and maintains effective work relationships

8. Maintains discretion and confidentiality

9. Travels and attend on-site visits, trainings, meetings, hearings

10. Physically moves materials

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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