R&E Nurse- Med Care Services- Expert

Company: TulaRay
Location: Harrisburg
Posted on: June 24, 2022

Job Description:

Job Description

Description of Work/Duties:

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 familiarity 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 will be provided with a desk, computer, phone, and all items necessary for him/her to complete assignments.

Additional work/duties for the Outpatient Prior Authorization Review Section:
Perform review by telephone of prior authorization requests for home health services, radiology services and other services as indicated by the prior authorization indicator on the reference file to ensure the services are medically necessary and compensable under the MA Program. (Meeting daily/monthly volumetric standards established).
Perform pre-admission review of all elective admissions of MA recipients to general hospitals, shor procedure untis and ambulatory surgical centers to evaluate the appropriate setting for services, to ensure medical necessity for the services, and the ensure the admission is complensable under the MA Program.
Review and evaluate medical information given by the practitioner or provider to ensure that services are medically necessary in accordance with applicalbe State and Federal MA laws and requlations, for Place of Service Review (PSR), ensures that care is certified for payment at the rat eof the appropriate setting in accordance with State and Federal laws and regulations.

Additional work/duties for the Shift Nursing, DME, Medical Supplies, Orthotics and Prosthetics Section:
Authorization requests are received via fax or mail and entered into the PROMISe system as indicated by the prior authorization indicator on the reference file to ensure the services are medically necessary and compensable under the MA Program.
Perform pre-admission review of all elective admissions of MA recipients to general hospitals, shor procedure untis and ambulatory surgical centers to evaluate the appropriate setting for services, to ensure medical necessity for the services, and the ensure the admission is complensable under the MA Program.
Review and evaluate medical information given by the practitioner or provider to ensure that services are medically necessary in accordance with applicalbe State and Federal MA laws and requlations, for Place of Service Review (PSR), ensures that care is certified for payment at the rat eof the appropriate setting in accordance with State and Federal laws and regulations.

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

Keywords: TulaRay, Harrisburg , R&E Nurse- Med Care Services- Expert, Healthcare , Harrisburg, Pennsylvania