R&E Nurse- Med Care Services- Expert
Company: TulaRay
Location: Harrisburg
Posted on: June 24, 2022
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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
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