R&e Nurse- Med Care Services

4 weeks ago

Harrisburg, United States TulaRay Full time

**DESCRIPTION OF WORK**

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.
The incumbent in this position must 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. The incumbent will provide supervisor and division director with written and verbal reports and make recommendations as appropriate. This position requires frequent statewide travel to conduct onsite reviews of Pennsylvania’s 19 LIFE Provider Organizations.

Incumbent would be 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.

The work in this position is done both at the worksite and in the field. Travel across the Commonwealth of PA is required, and can be at very short notice.
Work hours and additional information:

- Full-time employment.
- Hours of work: Monday through Friday, 8:30 AM - 5:00 PM; 1 hour lunch.
- Overtime may be required.
- This position will be telework eligible

**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

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