RN-Review/Evaluation Med Care Service (2173)
Administrative Nurse | Harrisburg, PA | Contract
RN-Review/Evaluation Med Care Service
Work Location: Harrisburg, PA
To review MDS (minimum data set) profiles (in skilled nursing facilities) for accuracy and source documentation; Review accuracy of the CMI (case mix index); Assist financial representatives with financial reviews in skilled nursing facilities; Review of clinical records for accuracy and content with ability to communicate effectively with co-workers and facility staff and provide technical assistance to facilities as/when needed. This position requires significant travel, mostly one day travel, overnight travel on occasion and daily travel to nursing facilities. This office and satellite office cover 17 counties and 126 skilled nursing facilities
Job Duties/Responsibilities/Functions(including but not limited to)
• Evaluate and review medical, physical, rehabilitative, restorative and other care being provided to determine appropriateness.
• Review, understand and relate pertinent Departmental, State and Federal policies, licensure requirements, and regulations to insure compliance by Medical Assistance (MA)/OLTL providers.
• Participate in the development of new and/or revision to existing medical assistance policies and regulations.
• Coordinate and interact with other Agencies and Departments to ensure appropriate services for individuals using long term living services.
• Perform monitoring reviews in all Long-Term Living settings in order to determine that the provision and adequacy of medical, social, physical, rehabilitative and restorative care services are being provided in accordance to all regulations and licensure criteria.
• Review Minimum Data Set (MDS) submitted to the MDS database for accuracy and documentation support in the clinical records.
• Review PA Pre-Admission Screening Resident Review (PA-PASRR-ID) process to assure nursing facilities (NF) compliance with the Omnibus Budget Reconciliation Act (OBRA).
• Perform evaluations of identified targeted individuals residing in long term care facilities including submission of packet with recommendations to the appropriate Program Office (OMHSAS, ODP, ORC, or DMVA) for review.
• Monitor appropriateness of NF admissions and determine need for continued stay by reviewing clinical records, evaluate discharge plans and interview staff and residents.
• Perform financial reviews to identify recoveries to ensure adjustments are made for any inappropriate payments or billings in accordance with established regulations and guidelines.
• Assist the Financial Representative with processing recoveries through reviewing supportive documentation and/or remittance advices submitted by the NF.
• Coordinate on-site NF reviews, including pre-review activities, entrance and exit conferences appropriate paperwork during the review and all post review activities.
• Perform follow up reviews to ensure compliance with corrective action plans as submitted by the nursing facility.
• Perform any specialized reviews and projects with MA/OLTL providers as necessary.
• Monitor individuals who receive services in the Ventilator and Durable Medical Equipment Programs to ensure that they continue to receive services and that they are using their DME as approved by the Program.
• Perform assessments for individuals in the Home and Community Based Waiver Programs (HCBS) as requested.
• Assist with other PDA and OLTL projects as an assessor or monitor of services, as necessary.
• Act as a resource for exchange of information through verbal and written communication with NF to enhance NF's awareness of applicable Federal and State regulations.
• Provide technical assistance to NF staff as needed to achieve NF compliance with applicable Federal, State and Department requirements pertaining to the Field Operations review process (MDS, OBRA, Financial).
• Process Facility Alert/Act 28 forms to notify appropriate agencies of any issues identified during reviews.
• Participate in formal training programs.
• Acquire knowledge and be proficient in the use of office equipment including laptop computer and relevant software.
• Performs other duties as assigned
• Possession of a current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing
• Possess excellent communication skills
• Proficient computer skills - knowledge of MS word and Excel programs
• Long term care experience is preferred
• MDS (minimum data set) experience preferred
• Utilization and review experience preferred
• OBRA experience and knowledge preferred
• Ability to formulate written/typed summaries and advisement about findings during a review
• Ability to present said findings to facility staff
• Ability to work independently and being self-directed is essential
• Ability to work in a team environment is also essential
• Reliable transportation and a valid driver’s license are required
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.
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.