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Registered Nurse - Review & Evaluation Med Care Service

Medical Auditor | Harrisburg, PA | Contract

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

Job Summary/Description
The RN is 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 Medical Assistance Program is properly billed, and that provider and/or recipient fraud, abuse and waste of the Medical Assistance Program is detected and corrected. Provides the knowledge and education that only an individual with a strong medical background can bring to the position.
Ensure the health and safety of participants receiving supports and services in a community-based setting. As part of the assurance, an internal review process that utilizes medical professionals to screen deaths for factors that would require further investigation, such as participant deaths correlated to an allegation of abuse or neglect, suicide, drug overdose, suspicious death, unexplained deaths, or potentially preventable deaths. The process is extensive and medically complex. There is a current back-log regarding this work. The RN will assist with the mortality review process in reviewing deaths, gathering supporting documentation, analyzing the data, completing the report for the mortality review team, and implementing recommendations from the mortality review team.

Job Duties/Responsibilities/Functions (including but not limited to)
• Ability to prepare correspondence and reports.
• Ability to comprehend and apply regulations, policies and standards.
• Ability to establish and maintain effective working relationships.
• Ability to carry out instructions and complete assignments.
• Ability to conduct field work, desk and telephonic reviews.
• Ability to travel to facilities/provider sites to conduct reviews and attend training and meetings as needed, across the State (includes overnight stays).
• Ability to communicate effectively (verbally and in writing) with coworkers, management, Office of General Counsel other agencies, nursing facility staff and other medical assistance providers to review and discuss cases.
• Ability to enter essential data into the computer.
• Ability to physically traverse stairs, lift laptop, printer and related equipment, walk long distances and sit for long periods of time.
• Ability to review and evaluate provider documentation to determine compliance with Medical Assistance regulations.
• Ability to testify at administrative/legal hearings and to defend Departmental decisions.
• Candidate must analyze and evaluate documentation submitted by the Medical Assistance Program service providers and generated through PROMISe™ in order to make professional medical judgments regarding the appropriateness of the Hospice care and services provided to eligible recipients under the Medical Assistance Program.
• Candidate will provide education to other staff, offices, and Department attorneys regarding current standards of Hospice care.
• Candidate will conduct reviews in the central office with the Medical Assistance Program service to organize and coordinate the review process.
• Candidate will also provide advisory and consultative services to boards and staff designed to improve the services or administrative procedures.
• The candidate may also represent the Department in an official capacity during an appeal process.
• Candidate must show a large degree of judgment and discretion.
• Performs other duties as assigned.

Minimum Qualifications
• Possession of a current license to practice as a Registered Nurse by the Pennsylvania State Board of Nursing; or
• Possession of a non-renewable temporary practice permit issued by the Pennsylvania State Board of Nursing. Candidates 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.
• Possession of current specialty certification as a Certified Hospice and Palliative Nurse issued by the National Board for Certification of Hospice and Palliative Nurses.
• Psychiatric or behavioral health background experience.
• 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 Hospice care, quality management/utilization review and other related clinical experience.
• Background in Long Term Living Care required
• 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.

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.