R&E Nurse- Med Care Services (679839)

JOB DESCRIPTION

This professional position is located in the Division of Provider Review of the Bureau of Program Integrity, Office of Administration.

The incumbent must hold a current valid Pennsylvania Registered Nurse license and participate in the operation of a program charged with the responsibility to protect the Medical Assistance Program from fraud, waste and abuse by performing in-house (desk top) and on-site reviews to verify and assess the medical care and services rendered by providers enrolled in the MA Program. specific duties are as follows:

a. Identifies discrepancies through the analysis of claims, itemized bills, and computer reports through 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.

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

c. Prepares case findings, prepares preliminary and final letters to providers, researches and utilizes appropriate MA regulations, MA bulletins and federal regulations. Recommends the type of administrative sanctions by consultation with supervisor, and meetings with the Office of General Counsel. 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 this section’s supervisor.

d. Coordinates and participates in teleconferences or meetings with providers or other interested stakeholders.

e. Prepares claims to recover money for violations identified during the review process.

f. Coordinates cases with the Office of General Counsel (legal office), preparing for, and testifying at provider hearings, potential face-to-face hearings and other court proceedings.

g. Prepares potential cases of fraud according to established procedures for referral to the Office of Attorney General’s Medicaid Fraud Control Section.

h. Prepares summaries of findings, reports, charts, forms and other related materials using Word and Excel computer programs to ensure efficient operations.

i. Participates in research and special study projects that identify and impact services delivered to MA recipients and paid for by the MA Program.

j. Attends in-service training to ensure proficiency and effectiveness of program operations.

k. Participates in conferences, meetings, seminars and work groups related to section’s duties and responsibilities.

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