R&E Nurse- Med Care Services (751398)

QUALIFICATIONS:

Licensed Registered Nurse (RN)

• Knowledge of Microsoft Office Suite programs including but not limited to Outlook, Teams, Word and Excel
• Long-term care experience is preferred
• Experience with reviewing medical records
• Experience with medical quality control with the ability to develop, apply, and review performance measures and the measures’ outcomes
• Effective verbal and written communication

MAJOR POSITION DUTIES AND RESPONSIBILITIES:

• Acquires knowledge of regulations, policies, procedures, and guidelines related to Emergency Medical Assistance (EMA) requests for non-citizens. Assist with assessments related to EMA requests. This includes collecting and reviewing all the necessary information for review. This position reviews EMAs with the OLTL Medical Director as necessary.
• Assists with reviewing and evaluating Medical Director Reviews (MDRs) related to Functional Eligibility Determination (FED) discrepancies between the FED and Physician Certification or MA 51. Acquire knowledge related to the determination of Nursing Facility Clinically Eligible (NFCE) and Nursing Facility Clinically Ineligible (NFI). This includes reviewing participant health information, three (3) months of service coordination notes, any related utilization management notes, person centered service plans, last two (2) InterRAIs, and any other information necessary for review.
• Assists with clinical reviews related to physical health (PH), pharmacy (RX) and home and community-based services (HCBS) denials submitted by Community HealthChoices Managed Care Organization (CHC-MCOs). Review of denial notices includes determining if an appropriate denial notice was used, if the denial was handled within the required timeframes, was the denial appropriately denied given the provided justification and if the appropriate appeal rights was included in the denial notice.
• Assists with reviewing and evaluating prior authorization review policies (PARP) submitted by the CHC-MCOs. Review of PARP policies includes determining whether the policy meets CHC-MCO Agreement requirements and if the policy is in-line with industry standards. The duty requires acquiring up-to-date knowledge on current medical policies and protocols. This position reviews PARP Policies with the OLTL Medical Director as needed.
• Assists with reviewing and evaluations the Quality Management Utilization Management (QMUM)-008 – Licensed Proprietary Product (LPP) Annual Report submitted by the CHC-MCOs. Review of the QMUM-008 LPP Annual Report includes determining if the CHC-MCO’s LPPs maintain current and, as applicable, clinically, and operationally appropriate LPPs according to nationally recognized medical standards of care. This position reviews LPPs with the OLTL Medical Director as needed.
• Assists with reviewing and evaluating Systematic Monitoring Access Retrieval Technology (SMART) standards assigned to the Clinical Review Team (CRT) in the Medicaid Enterprise Monitoring Module (MEMM). Review of the standards includes determining if the CHC-MCOs are following requirements set forth in the CHC Agreement. The position reviews SMART standards with the CRT Section Chief as needed.
• Assist with the development of monitoring tools to support the CRT.
• The employee is required to have working knowledge of basic personal computer analysis tools such as Microsoft Excel and server-based tools such as Docushare, Pennsylvania Individualized Assessments System (PIA), MEMM, SMART, and Client Information System (CIS).
• Participate in meetings related to the CHC-MCOs, HCBS, Nursing Facility and Quality Management programs within the Office of Long-Term Living (OLTL).
• Write and revise internal protocols for the CRT.
• Participate in the development of new and/or revisions to existing HCBS policies.
• Provide technical assistance and training to Provider staff and OLTL staff as needed.
• Participate in required training programs.
• Coordinate Meetings, as necessary with CRT and internal/external parties when needed to collaborate on Policy and other duties required in the course of the job description.
• Perform other related job duties.

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