Job Description

Consultant will:

Be available as a full time consultant approximately 37.5 hours per week;

Possess an active Pennsylvania Registered Nurse License issued by the Pennsylvania State Board of Nursing; or possesion 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;

Possess a documented work history of three or more years of professional experience with medical assistance, health care services or human services or any equivalent combination of experience and training;

Possess basic computer skills, including familiarty with Microsoft Office programs;

Perform review and evaluation of medical information and examination of medical records to assure the medical necessity, appropriateness, quality, quantity, adequacy and compensability of medical care and services under the Medical Assistance Program;

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 MA program is properly billed, and that provider and/or recipient fraud and abuse of the MA program is detected and corrected.

Documentation submitted by the MA service providers and generated thru the Departments payment system is analyzed and evaluated. These documents can be provided over the phone, by fax and/or US mail.

Provide problem solving solutions to supervisor and Division Director to improve the services or administrative procedures in support of MA patients.

Perform other related duties as assigned by the managerial staff.

Approve, approve other than as requested, and deny requests or refer the request to a physician consultant to discuss the medical necessity of the requested service, appropriate setting, and/or the compensability of the service.

Consult with the physician/medical consultant on cases for which the medical need for the requested services/items is unclear and arranges telephone calls between the physician consultant and the ordering physician for further discussion of the need for the service/item or for further discussion on the appropriate setting for the service.

Enter the appropriate data and decision into the computerized system, which generates notification letters to the practitioner, provider, facility, and/or recipient to provide the authorization number for billing purposes, the reason code for denials, and the appeal process.

Consult with the physician/medical consultant when a re-evaluation of a case is requested by a practitioner, provider, or facility to reconsider a previously denied service.

Evaluate appeal requests and medical records; prepares cases, exhibits and appeal correspondence; testify at appeal hearings by utilizing knowledge of MA regulations and appeal procedures; and prepare petitions for Reconsiderations.

Interpret MA policies, regulations and procedures to agency or office staff via telephone conversations. Attends workshops, and/or meetings to ensure a working knowledge in these areas.

Attend staff meetings for the purpose of information sharing regarding MA policies, regulations, and review procedures.

Maintain continuing education through conferences and the reading of medical journals and documents to keep abreast of current trends for treatment of medical conditions to ensure that proper decisions regarding medical necessity and appropriateness of services is met.

Relieve in other sections as required in order to maintain all program functions. Updates and training in the processes will be scheduled as necessary to ensure a working knowledge in the different areas.

Respond to inquiries/correspondence from recipients, providers, legislators, legal office and other agencies concerning the program in order to explain regulations, operational methods, and administrative procedures and decisions.

Files and retains records in accordance with MA regulations and policies.

Performs related work as required and special projects as assigned. Purpose and standards are given at the time of each assignment.

Consultant, when requested, will work at one or more of the Department's work sites. Consultant's primary work location will be in Harrisburg, PA. Consultant will be provided with a desk, computer, and all items necessary for them to complete assignments.

Additional work/duties for the Paper Prior Authorization/Program Exception Review Section:

Performs a review of outpatient service authorization requests for Prior Authorization and 1150 Waiver (Program Exception) for PSR/PE, medical supplies, prosthesis, orthotics, durable medical equipment, requests for skilled nursing care and home health aide care, and emergency medical services for non-citizens to ensure the items/services are medically necessary and compensable under the Medical Assistance (MA) Program.

Refer program exception requests as needed to Rate Setting to determine pricing for non-fee schedule items or when the provider requests additional monies for a fee schedule item. Program exception requests submitted to the department for limits above the allowed Fee Schedule quantity, reviewer should assign fee at system price unless additional monies are requested by the provider. (Meeting daily/monthly volumetric standards established).

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

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