Minimum Qualifications

Possession of a current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing; or Possession 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.
Proficient writing and basic Computer Skills to include, but not limited to, Microsoft Office Products
Three years of professional experience with medical assistance (MA), health care services, or human services
Minimum of three years of recent (within the last five years) professional experience in one or more of the following areas as related to the position need: long term care, acute care setting, behavioral health setting, drug and alcohol setting, managed care, quality management/utilization review or other related clinical experience; or An equivalent combination of experience and training in the field of medical assistance (MA), health care services, human services, long term care, utilization review, or knowledge of home care
Knowledge of and familiarity with the following would be beneficial: Inter- Qual criteria, ICD-9 CM, and current procedure terminology, Ability to use professional judgment in identifying aberrant patterns and determining the appropriate action to be taken following the documentation review.

Role Description

Identify discrepancies through the analysis of paid claims, itemized bills, and computer reports through the Fraud Abuse Detection System(FADS). This includes but is not limited to analysis of paid claims for patterns identified with high-cost, high-volume providers, and potential cases for review.

Select, review, analyze and evaluate cases retrospectively to monitor compliance with State and Federal Regulations. Services are monitored for medical necessity and quality of care. Verifying that services ordered were rendered, and all rendered services were ordered and are appropriate. Analyze for up coding, duplicated billing and unbundling of services billed. Use the ICD-9CM diagnosis and procedure manuals, coding clinics, CPT and HCPCS manuals, and other related manuals to determine that the paid claim was billed appropriately.

Prepare case findings, prepare preliminary and final letters to providers, research and utilize appropriate MA regulations, MA bulletins and federal regulations. Keep the section supervisor informed of case development and progress as well as keep the Bureau’s Case Tracking system and the Sections tracking system updated for each active case.

Coordinate and participate in teleconferences, when requested by the provider, scheduling times/dates with supervisor, Division Director, physician consultants and/or other parties involved with the case.

Prepare claims to recover money for violations identified during the review process.

Coordinate cases with the Office of General Counsel (Legal Office) in preparation for testifying at provider hearings, potential face-to-face hearings and other court proceedings. As well as discussing recommended sanctions for MA violations in accordance with Department guidelines.

Respond to complaints from multiple sources including, but not limited to MCO, MA Provider Compliance Hotline, OMAPTips web site, letters, e-mail and phone.

Prepare potential cases of fraud according to established procedures for referral to the Office of Attorney General’s Medicaid Fraud Control Section.

Prepare summaries of findings, reports, charts, forms and other related materials using Word and Excel computer programs to ensure efficient operations.

Participate in managed care monitoring in conjunction with the Bureau’s Managed Care Section’s ongoing managed care projects.

Participate in research and special study projects that identify and impact health care services delivered to MA recipients and paid for by the MA Program.

Attend in-service training to ensure proficiency and effectiveness of program operations.

Participate in conferences, meetings, seminars and work groups related to sections duties and responsibilities.

Perform other related duties and special projects as assigned by the Supervisor in order to meet the goals and objectives of BPI.

Essential Functions

Knowledge/use of Microsoft Office products
Communicate effectively, verbal/written
Prepare correspondence and reports
Testify at legal proceedings
Comprehend & apply rules/regulations
Complete assignments per procedures in a timely manner
Establish and maintain effective work relationships
Maintain discretion and confidentiality
Travel and attend on-site visits, trainings, meetings, hearings
Physically move materials

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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