R&E Nurse- Med Care Services

R&E Nurse Med Care Services

Type of Position: full-time

Anticipated Start Date: 02/01/2026

Anticipated End Date: 01/31/2031

Length of time needed: long-term

Number of hours per week: 37.5

Location of Position: Bureau of Fee-for-Service Programs

Description of Work/Duties: Consultant will:

• Be available as a full-time consultant, approximately 37.5 hours per week;
• Possess a current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing; or possess 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 (3) 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.

Principal Duties and Responsibilities:

• Perform review and evaluation of medical information and examination of medical records to assure the medical necessity, appropriateness, quality, 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 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 through the Department's payment system is analyzed and evaluated. These documents can be provided through an electronic provider portal, 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 review 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 arrange 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; prepare 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. Attend workshops and/or meetings to ensure a working knowledge in these areas;
• Attend staff meetings for the purpose of sharing information regarding MA policies, regulations, and review procedures;
• Maintains 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 are 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 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, phone, and all items necessary for them 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 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, short procedure units, and ambulatory surgical centers to evaluate the appropriate setting for services, to ensure medical necessity for the services, and to ensure the admission is compensable 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 applicable State and Federal MA laws and regulations, for Place of Service Review (PSR), ensures that care is certified for payment at the rate of 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, short procedure units, and ambulatory surgical centers to evaluate the appropriate setting for services, to ensure medical necessity for the services, and to ensure the admission is compensable 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 applicable State and Federal MA laws and regulations, for Place of Service Review (PSR), ensures that care is certified for payment at the rate for the appropriate setting and is in accordance with applicable State and Federal MA laws and regulations.

Additional work/duties for the Inpatient Clinical Review Section:

• Performs an admission review of all urgent and emergency admissions to general hospitals and short procedure units; and/or elective admissions to medical rehabilitation hospitals; to evaluate the medical necessity and the appropriate setting for the services to ensure that the admission is medically necessary and compensable under the MA program.
• Reviews and evaluates medical information given by the facility during the scheduled call or via the electronic review to assure that care is certified for payment at the rate for the appropriate setting and is in accordance with applicable State and Federal MA laws and regulations.
• Certifies urgent and emergency admissions and/or medical rehab admissions, or refers the request to the physician consultant for the appropriate setting or compensability of the case.

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).

Requestor: April Lebo

Requestor Phone Number: View phone number on click.appcast.io

This position may be eligible for part-time telework. This position is currently expected to work in the office location in Harrisburg two (2) days per week; however, this could change at any time as directed by the commonwealth onsite supervisor.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.