R&E Nurse- Med Care Services (660443)

Minimum Qualifications:

• Possession of a current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing; or Possession of a non-renewable temporary practice permit issued by the Pennsylvania State Board of Nursing.
• Resources 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.
• 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 one or more of the following areas as related to the position need: long term care, acute care setting, behavioral health setting, drug and alcohol setting, managed care, quality management/utilization review or other related clinical experience; or
  An equivalent combination of experience and training in the field of medical assistance (MA), health care services, human services, long term care, utilization review, or knowledge of home care
• 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.

Specific duties are as follows:

Identify discrepancies through analysis of computer reports, PROMISe™ claims history profiles, MCO encounter data, other Medical Assistance (MA) documents and referrals/complaints in order to select MCO participating providers for review of compliance with MA Program regulations and other state/federal requirements.

Function as case coordinator for assigned cases by planning and conducting retrospective review activities to complete the case in an efficient/ timely manner.

Perform in house and on-site reviews and recipient interviews to verify/assess the medical care rendered by providers, including the review of medical and fiscal records, MCO documentation, and MCO policy and payment information.

Coordinate, schedule and participate in teleconferences and meetings when requested by the provider, to include physician consultant, DPW legal counsel, MCOs and provider, as applicable, to discuss review processes/case findings.

Participate in evidentiary meetings with the Section Supervisor/Division Director, in-house medical staff, legal counsel, MCO staff, or other offices/agencies by discussing the provider case history, case strategy, and findings to recommend sanctions in accordance with Department guidelines and to prepare for litigation proceedings.

Prepare written material in the course of the reviews by writing memoranda, letters, and reports as indicated in order to provide care findings and violations, refer information to other agencies, to communicate with recipients and providers, or to carry out necessary review activities.

Respond to complaints from multiple sources including, but not limited to MCO, MA Provider Compliance Hotline, OMAPTips web site, letters, e-mail and phone.

Performs other related duties and special projects as assigned by the Supervisor in order to meet the goals and objectives of the BPI.

Essential Functions:

1. Knowledge/use of Microsoft Office products
2. Communicate effectively, verbal/written
3. Prepare correspondence and reports
4. Testify at legal proceedings
5. Comprehend & apply rules/regulations
6. Complete assignments per procedures
7. Establish and maintain effective work relationships
8. Maintain discretion and confidentiality
9. Travel and attend on-site visits, trainings, meetings, hearings
10. Physically move materials

About Us:

TulaRay partners with clients to create staffing solutions that meet unique organizational needs. Our services are designed to reduce administrative burdens, protect your brand, and improve assignment time-to-fill. We believe that mutually successful client relationships are built on lasting quality and exceptional customer service. We pride ourselves on our uncompromising commitment to high-quality emergency management & healthcare personnel, while ensuring that our clients are taken care of with personalized attention. TulaRay manages total compliance and respectfully supports hundreds of professionals and patient-centered programs.

TulaRay is proud to be an affirmative action employer and is committed to providing equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you have a disability or special need that requires accommodation, please let us know by visiting our website at tularay.com