Utilization Review Nurse – $33.70 per hour/ Full-time Role – Hybrid Position Available In Dauphin, Pennsylvania

Job Description:

Consultant will: Be available as a full time consultantapproximately 37.5 hours per week; Possess an active PennsylvaniaRegistered Nurse License issued by the Pennsylvania State Board ofNursing; or possesion of a non-renewable temporary practice permitissued by the Pennsylvania State Board of Nursing. Resourcespossessing non-renewable temporary practice permits must obtainlicensure as a Registered Nurse within the one year period asdefined by the Pennsylvania State Board of Nursing; Possess adocumented work history of three or more years of professionalexperience with medical assistance, health care services or humanservices or any equivalent combination of experience and training;Possess basic computer skills, including familiarty with MicrosoftOffice programs; Perform review and evaluation of medicalinformation and examination of medical records to assure themedical necessity, appropriateness, quality, quantity, adequacy andcompensability of medical care and services under the MedicalAssistance Program; Responsible for the review and evaluation ofmedical information and examination of medical records and otherdocumentation to assure that eligible medical assistance recipientsreceive appropriate and quality medical care, that the MA programis properly billed, and that provider and/or recipient fraud andabuse of the MA program is detected and corrected. Documentationsubmitted by the MA service providers and generated thru theDepartments payment system is analyzed and evaluated. Thesedocuments can be provided over the phone, by fax and/or US mail.

Provide problem solving solutions to supervisor and DivisionDirector to improve the services or administrative procedures insupport of MA patients. Perform other related duties as assigned bythe managerial staff. Approve, approve other than as requested, anddeny requests or refer the request to a physician consultant todiscuss the medical necessity of the requested service, appropriatesetting, and/or the compensability of the service. Consult with thephysician/medical consultant on cases for which the medical needfor the requested services/items is unclear and arranges telephonecalls between the physician consultant and the ordering physicianfor further discussion of the need for the service/item or forfurther discussion on the appropriate setting for the service.

Enter the appropriate data and decision into the computerizedsystem, which generates notification letters to the practitioner,provider, facility, and/or recipient to provide the authorizationnumber for billing purposes, the reason code for denials, and theappeal process. Consult with the physician/medical consultant whena re-evaluation of a case is requested by a practitioner, provider,or facility to reconsider a previously denied service. Evaluateappeal requests and medical records; prepares cases, exhibits andappeal correspondence; testify at appeal hearings by utilizingknowledge of MA regulations and appeal procedures; and preparepetitions for Reconsiderations. Interpret MA policies, regulationsand procedures to agency or office staff via telephoneconversations. Attends workshops, and/or meetings to ensure aworking knowledge in these areas. Attend staff meetings for thepurpose of information sharing regarding MA policies, regulations,and review procedures. Maintain continuing education throughconferences and the reading of medical journals and documents tokeep abreast of current trends for treatment of medical conditionsto ensure that proper decisions regarding medical necessity andappropriateness of services is met. Relieve in other sections asrequired in order to maintain all program functions. Updates andtraining in the processes will be scheduled as necessary to ensurea working knowledge in the different areas. Respond toinquiries/correspondence from recipients, providers, legislators,legal office and other agencies concerning the program in order toexplain regulations, operational methods, and administrativeprocedures and decisions. Files and retains records in accordancewith MA regulations and policies. Performs related work as requiredand special projects as assigned. Purpose and standards are givenat the time of each assignment. Consultant will be provided with adesk, computer, and all items necessary for him/her to completeassignments. Additional work/duties for the

Inpatient ClinicalReview Section:

Performs an admission review of all urgent andemergency admissions to general hospitals and short procedureunits; and/or elective admissions to medical rehabilitationhospitals; to evaluate the medical necessity and the appropriatesetting for the services to ensure that the admission is medicallynecessary and compensable under the MA program. Reviews andevaluates medical information given by the facility during thescheduled call or via the electronic review form to assure thatcare is certified for payment at the rate for the appropriatesetting and is in accordance with applicable State and Federal MAlaws and regulations. Certifies urgent and emergency admissionsand/or medical rehab admissions, or refers the request to thephysician consultant for the appropriate setting or compensabilityof the case.