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Registered Nurse / RN - Review & Evaluation (1803)

Medical Auditor | Harrisburg, PA | Contract

Job Description
Registered Nurse / RN – Review & Evaluation
Work Location: Harrisburg, PA

InGenesis is currently seeking a Registered Nurse / RN to review and evaluate medical information/records to assure the medical necessity, appropriateness, and quality of care and services under the Medical Assistance Program. If you meet the qualifications outlined below, apply today and we’ll reach out to answer any questions you may have!

Job Duties
• Ensure services are properly billed.
• Detect and correct provider or recipient fraud/abuse.
• Analyze documentation submitted by service providers and generated thru payment system.
• Provide problem solving solutions to improve services or administrative procedures.
• Approve, deny, or refer requests.
• Consult with physician consultant on unclear cases.
• Arrange calls between physician consultant and ordering physician for further.
• Enter appropriate data and decision into computerized system.
• Consult with physician consultant when a case re-evaluation is requested.
• Evaluate appeal requests and medical records.
• Prepare cases, exhibits, and appeal correspondence.
• Testify at appeal hearings.
• Prepare petitions for reconsiderations.
• Interpret medical assistance policies, regulations, and procedures to agency or office staff.
• Attend workshops or meetings to maintain working knowledge in these areas.
• Attend staff meetings for the purpose of information sharing.
• Respond to internal/external inquiries and correspondence to explain regulations, operational methods, and administrative procedures/decisions.
• File and retain records in accordance with regulations and policies.
• Perform other duties as necessary or assigned.

Minimum Qualifications
• Current Registered Nurse / RN license issued by the state of Pennsylvania.
• 3+ years of documented work history with medical assistance, health care services, human services, OR any equivalent combination of experience and training.
• Basic computer skills, including familiarity with Microsoft Office programs.