Physician Specialist (2010)
Consultant | Harrisburg, PA | Contract
Work Location: Harrisburg, PA
The Physician Specialist (PS) will provide consultant services for the Department of Human Services, Office of Long-Term Living’s (OLTL) programs. OLTL’s program include: (1) managed care program, the Community HealthChoices (CHC); and, (2) the fee for services (F4S) program serving older adults and adults with physical disabilities. The Physician Specialist will provide utilization and quality review of services; provide clinical input into projects in conjunction with the Office of Long-Term Living Programs Chief Medical Officer. The Physician Specialist will be provided with a desk and computer, and all items necessary to complete assignments.
Job Duties/Responsibilities/Functions(including but not limited to)
• Responsible to compile case findings, prepare summaries of case findings; make recommendations for case disposition, identify program violations; prepare appealed cases for hearings; and/or be available to testify at administrative hearings either in person or by phone for cases under appeal. The PS will submit the above information in a timely basis to the Department using formats specified by OLTL. Some work product deliverables include:
• Assist in the development of training, conduct presentations, and provide technical support to both internal and external audiences as requested by OLTL. This includes but is not limited to the Medical Assistance Advisory Committee (MAAC) and the Managed Long-Term Care Services and Support Subcommittee.
• Provide technical support and represent OLTL in the development and implementation of DHS health related policies and procedures;
• Develop, implement and evaluate clinical review policies, procedures and regulations to increase the continuity, cost-effectiveness and quality of health care services provided through the Department’s voluntary and mandatory managed care, fee for-service and long-term care programs. Serve as a resource for other OLTL managers and meet these deliverables in a timely basis as established by
• Provide support to OLTL’s managed care organizations (MCO) and Fee-For-Service Programs (FFSP). Oversee clinical quality management programs for MCOs and FFSP vendor’s contracting with OLTL.
• Support efforts led by the Medical Director within OLTL and be responsible for developing agenda items and leading discussions.
• Consultation with OLTL Executive Staff, managers and clinical staff regarding health care practices and clinical services such as: treatment, licensure, certification, accreditation program management reviews and program related issues. Establish and implement standards of care and clinical quality and risk management mechanisms. Advise the executive staff on general policies and procedures, with emphasis on the long-term care delivery continuum.
• Collaborate and coordinate with attending physicians and other physician reviewers within DPW to examine medical records and care plans of residents in long term care facilities to determine whether a specific incident, in a long-term care setting, constitutes a preventable serious adverse event (PSAE).
• Participate in the medical oversight of the quality assessment and performance improvement program for the Medicare Improvements for Providers and Patients Act of 2008 (MIPPA) by monitoring and evaluating the delivery of medical care and clinical outcomes in specific cases.
• Participate in Commonwealth activities related to electronic medical records, and other advancements in the technology of health information exchange.
• PS will report to the Bureau Director of Quality Assurance and Program Analytics.
• On a weekly basis, the PS will complete a time sheet which will be verified and approved by the Bureau Director. Payment will be made after services are actually rendered by the PS. If the PS is unable to appear at the scheduled work site at the pre-determined times, notification must be made to the work site supervisor either prior to date or on date of absence.
• In all cases wherein the PS has a personal relationship with any individual or entity involved in the matter requiring consultative services, or in any other situation where the PS might be perceived to have a conflict of interest, PS shall immediately notify the Department and excuse herself/himself from any further participation in the consultative process.
• The PS acknowledges that, in performing consultative services, PS shall be made privy to information of a confidential nature, including but not limited to information regarding the medical history of the MA recipient. PS hereby covenants to maintain the confidentiality of all such information, to the extent required by law and medical ethics. PS shall only discuss such confidential information to other medical experts to the extent necessary to provide the consultative services contemplated herein and only after prior notice to the Department of intent to so disclose. Performs other duties as assigned.
• Possess an active Pennsylvania medical license
• Be board certified as a Gerontologist; or board certification in Internal Medicine with demonstration of high volume of more than 50% patient population elderly
• Be very familiar with the Dual Eligible and LTSS populations to be enrolled in CHC and OLTL LTSS programs;
• Be familiar with Managed Care and Managed Long-term Services and Supports programs
• Be familiar with Medicare program requirements
• Be in active clinical practice in the area in which the consultant is board certified a least twenty (20) hours per month
• Demonstrate an understanding of the utilization review processes
• Demonstrate an understanding of the process associated with the review and approval of Medical Policy documents
• Possess basic computer skills, including familiarity with Microsoft Office programs
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