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Registered Nurse - Review & Evaluation Med Care Service (1803)

Medical Auditor | Harrisburg, PA | Contract

Job Description

Registered Nurse – Review & Evaluation Med Care Service
Work Location: Harrisburg, PA


Job Summary/Description

The Registered Nurse in this role will perform reviews and evaluations of medical information and examination of medical records to assure the medical necessity, appropriateness, quality, quantity, adequacy and compensability of medical care and services under the Medical Assistance Program. If you meet the qualifications, please apply and a Recruiter will reach out to you and answer any questions you may have.


Job Duties/Responsibilities/Functions(including but not limited to)

• Responsible for the review and evaluation of medical information and examination of medical records and other documentation to assure that eligible medical assistance recipients receive appropriate and quality medical care, that the MA program is properly billed, and that provider and/or recipient fraud and abuse of the MA program is detected and corrected.

• Documentation submitted by the MA service providers and generated thru the Departments payment system is analyzed and evaluated. These documents can be provided over the phone, by fax and/or US mail.

• Provide problem solving solutions to supervisor and Division Director to improve the services or administrative procedures in support of MA patients.

• Approve, approve other than as requested, and deny requests or refer the request to a physician consultant to discuss the medical necessity of the requested service, appropriate setting, and/or the compensability of the service.

• Consult with the physician consultant on cases for which the medical need for the requested services/items is unclear and arranges telephone calls between the physician consultant and the ordering physician for further discussion of the need for the service/item or for further discussion on the appropriate setting for the service.

• Enter the appropriate data and decision into the computerized system, which generates notification letters to the practitioner, provider, facility, and/or recipient to provide the authorization number for billing purposes, the reason code for denials, and the appeal process.

• Consult with the physician consultant when a re-evaluation of a case is requested by a practitioner, provider, or facility to reconsider a previously denied service.

• Evaluate appeal requests and medical records; prepares cases, exhibits and appeal correspondence; testify at appeal hearings by utilizing knowledge of MA regulations and appeal procedures; and prepare petitions for Reconsiderations.

• Interpret MA policies, regulations and procedures to agency or office staff via telephone conversations. Attends workshops, and/or meetings to ensure a working knowledge in these areas.

• Attend staff meetings for the purpose of information sharing regarding MA policies, regulations, and review procedures.

• Maintain continuing education through conferences and the reading of medical journals and documents to keep abreast of current trends for treatment of medical conditions to ensure that proper decisions regarding medical necessity and appropriateness of services is met.

• Relieve in other sections as required in order to maintain all program functions. Updates and training in the processes will be scheduled as necessary to ensure a working knowledge in the different areas.

• Respond to inquiries/correspondence from recipients, providers, legislators, legal office and other agencies concerning the program in order to explain regulations, operational methods, and administrative procedures and decisions.

• Files and retains records in accordance with MA regulations and policies.

• Performs related work as required and special projects as assigned. Purpose and standards are given at the time of each assignment.


Minimum Qualifications

• Possess an active Pennsylvania Registered Nurse License 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

• Possess a documented work history of three (3) or more years of professional experience with medical assistance, health care services or human services or any equivalent combination of experience and training.

• Possess basic computer skills, including familiarity with Microsoft Office programs.


About InGenesis

InGenesis is dedicated to placing people in positions that preserve life, improve lives and inspire others. This does not happen without passionate people, skilled colleagues who are motivated to create innovative solutions and deliver superior service to our clients. Founded in 1998, InGenesis manages thousands of employees, including pioneering healthcare, science, technology and pharma professionals. The workforce solutions company includes almost half of the Fortune 500 in its nearly 300 clients. It is recognized as one of the largest healthcare staffing firms, and InGenesis is the largest minority/women owned healthcare staffing firm in North America.


EEOC Statement

We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.