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RN-Review/Evaluation Med Care Service (2586)

Administrative Nurse | Harrisburg, PA | Contract

Job Description
RN-Review/Evaluation Med Care Service
Work Location: Harrisburg, PA

Job Summary/Description
Participates in the operation of retrospective fraud and abuse program which includes in-house and on-site reviews to verify and assess the medical care rendered by providers enrolled in the MA Program.

Job Duties/Responsibilities/Functions (including but not limited to)
• Identifies discrepancies through the analysis of paid claims, 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, analyze and evaluate cases retrospectively to monitor compliance with State and Federal Regulations. Services are monitored for medical necessity and quality of care. Verifying that services ordered were rendered, and all rendered services were ordered and are appropriate.
• Prepares case findings, consults with physician consultant, prepares preliminary and final letters to providers, researches and utilizes appropriate MA regulations, Ma bulletins and federal regulations. 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.
• Coordinates and participates in teleconferences, when requested by the provider, scheduling times/dates with physician consultant and providers.
• Prepares claims to recover money for violations identified during the review process.
• Performs other duties as assigned.

Minimum Qualifications
• Basic Computer Skills -Required
• Knowledge of Inter-Qual Criteria and ICD-9 CM- Desired
• Registered Nurse State License - Required

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.