Pharmacy/Ambulance/SBAP Services Review

Job Description

Job Description

Position Overview

This Registered Nurse position is located within the Division of Program and Provider Compliance Review, Bureau of Program Integrity (BPI), Office of Medical Assistance (MA) Programs .

Working under the direction of the section supervisor, the RN will participate in the retrospective Fraud and Abuse Program, conducting comprehensive medical record reviews and evaluating healthcare services provided by providers enrolled in Pennsylvania's Medical Assistance Program.

The primary focus of this position is to identify potential fraud, waste, and abuse, evaluate medical necessity and quality of care, and ensure provider compliance with applicable state and federal healthcare regulations.

Key Duties & Responsibilities

1. Claims Analysis & Fraud Detection

• Analyze paid claims and reports generated through the Fraud Abuse Detection System (FADS).
• Identify discrepancies, unusual billing patterns, and potential compliance concerns.
• Review claims associated with high-cost and high-volume providers.
• Identify potential cases requiring further investigation or retrospective review.

2. Medical Record Review & Clinical Evaluation

• Select, review, analyze, and evaluate retrospective cases to monitor compliance with state and federal regulations.
• Assess medical necessity and quality of care associated with services provided.
• Verify that services ordered were actually rendered and were appropriate.
• Evaluate clinical documentation and supporting medical records for accuracy and compliance.

3. Case Documentation & Provider Correspondence

• Prepare detailed case findings and medical record requests.
• Draft preliminary and final correspondence to healthcare providers.
• Research and apply applicable Medical Assistance regulations, MA bulletins, and federal regulations.
• Maintain communication with the section supervisor regarding case development and review progress.
• Utilize the Fraud Capture system for case tracking and documentation.
• Prepare official correspondence under the direction of the section supervisor.

4. Provider Communication & Coordination

• Coordinate and participate in teleconferences when requested by healthcare providers and/or Managed Care Organizations (MCOs).
• Communicate review findings and address questions related to the review process.
• Collaborate with providers and relevant organizations to support case resolution.

5. Claims Recovery & Financial Accountability

• Prepare claims for the recovery of funds associated with violations identified during the review process.
• Support financial recovery efforts resulting from identified billing discrepancies or program violations.

6. Legal Coordination & Provider Hearings

• Coordinate cases with the Office of General Counsel (legal office).
• Prepare supporting documentation for provider hearings and potential face-to-face hearings.
• Assist with preparation for other legal proceedings related to case findings and compliance matters.

7. Fraud Investigations & Referrals

• Prepare potential fraud cases in accordance with established procedures.
• Coordinate referrals to the Office of the Attorney General's Medicaid Fraud Control Section (MFCS).
• Ensure appropriate documentation and supporting evidence are prepared for potential fraud referrals.

8. Reporting & Administrative Support

• Prepare summaries of findings, reports, charts, forms, and other related materials.
• Utilize Microsoft Office applications to support documentation, reporting, and efficient program operations.
• Maintain organized case records and supporting documentation.

9. Training & Professional Development

• Attend required training sessions to maintain proficiency and effectiveness in program operations.
• Participate in conferences, meetings, seminars, and workgroups related to the section's responsibilities.
• Maintain knowledge of applicable regulations, policies, and procedures governing the Medical Assistance Program.

Overall Position Objective

Support the integrity of Pennsylvania's Medical Assistance Program by conducting thorough clinical and claims reviews, identifying potential fraud and abuse, evaluating medical necessity and quality of care, and ensuring healthcare providers comply with applicable state and federal requirements.

The RN will play an important role in protecting program resources, promoting accountability, and helping ensure that Medical Assistance recipients receive appropriate and medically necessary healthcare services.

Pleasant office environment. The CK Hobbie Group is a fifty-six year old recruiting and staffing business

Company Description

Pleasant office environment. The CK Hobbie Group is a fifty-six year old recruiting and staffing business