RN-Review and Evaluation
Health Care | Harrisburg, PA | Full Time
RN-Review and Evaluation of Medical Care and Services
Non Direct Patient Care
InGenesis is seeking qualified RN's to provide services to the Commonwealth of Pennsylvania. The position offers a structured schedule which allows for a great work/life balance all while servicing your local government and making a difference in your community.
Duties include but are not limited to:
Candidate 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.
- 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 central office with the Medical Assistance Program service organizing and coordinating the review process.
- Candidate will also provide advisory and consultative services to boards and staff designed to improve the services or administrative procedures.
- Candidate may also represent the Department in an official capacity during an appeal process.
- Candidate must show a large degree of judgment and discretion.
ESSENTIAL JOB FUNCTIONS
- 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, and other agencies and 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 Department decisions;
- Ability to maintain discretion and confidentiality.
- 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.
- 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.
- 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.
- Psych or Behavioral background preferred