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Registered Nurse / RN - Review & Evaluation (1995)

Administrative Nurse | Harrisburg, PA | Contract

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

In this role, the Registered Nurse will participate in the operation of a program charged with the responsibility to protect from fraud, waste and abuse. In this role, the RN is responsible for reviewing and evaluating the medical necessity, appropriateness, quality, quantity, adequacy and compensability of medical care and services rendered by inpatient providers. If you meet the qualifications, please apply and a Recruiter will reach out to you and answer any questions you may have.

Job Duties
• 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.
• 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.
• 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.
• Prepares claims to recover money for violations identified during the review process.
• 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.
• Coordinates schedules and participates in teleconferences and meetings when requested by the providers, to include physician consultants, DPW legal counsel, and Medical Assistance providers, as applicable, to discuss review processes/case findings.
• Prepares potential cases of fraud according to established procedures for referral to the Office of Attorney General’s Medicaid Fraud Control Section.
• Prepares summaries of findings, reports, charts, forms and other related materials using Word and Excel computer programs to ensure efficient operations.
• Participates in research and special study projects that identify and impact services delivered to MA recipients and paid for by the MA Program.
• Attends in-service training to ensure proficiency and effectiveness of program operations.
• Participates in conferences, meetings, seminars and work groups related to section’s duties and responsibilities.
• Performs other duties as assigned

Minimum Qualifications
• Possess a current valid Pennsylvania Registered Nurse license
• Possess basic computer skills, including familiarity with Microsoft Office programs
• Experience in verifications and assessments in medical care and services rendered by providers highly preferred
• Solid Acute Care Experience; could include medical surgical nursing and/or intensive/critical care, hands on nursing, Emergency Room experience
• Five (5) years of nursing experience
• Knowledge/use of Microsoft Office products, with proficiency in Excel
• Ability to communicate effectively, verbal/written
• Ability to prepare correspondence and reports
• Ability to testify at legal proceedings
• Ability to comprehend & apply rules/regulations
• Ability to complete assignments per procedures
• Ability to establish and maintain effective work relationships
• Ability to maintain discretion and confidentiality
• Ability to travel and attend on-site visits, trainings, meetings, hearings