Medical Records Examiner

Commonwealth Of Pennsylvania

387d • $66,250 - $100,636 • Remote

About The Position

The Medical Records Examiner position within the Bureau of Program Integrity, Division of Program and Provider Compliance, offers a unique opportunity for Registered Nurses with outpatient and/or Medical-Surgical experience to engage in Medicaid case review. The role involves evaluating the medical necessity and quality of care provided to recipients under the Medical Assistance Program, ensuring compliance with regulations, and preparing detailed reports on findings and recommendations.

Requirements

• Three years of professional experience in medical assistance, health care services, or human services; or an equivalent combination of experience and training.
• Active authorization to practice as a Registered Nurse in Pennsylvania.

Nice To Haves

• Experience in Medicaid case review.
• Strong analytical skills.
• Excellent communication skills.

Responsibilities

• Review and evaluate medical necessity, appropriateness, quality, quantity, and adequacy of medical care and services rendered to recipients under the Medical Assistance Program.
• Identify discrepancies by analyzing provider invoices, claims history profiles, medical records, and other medical assistance documents.
• Function as case coordinator for assigned cases, planning and directing review activities to ensure timely completion.
• Prepare reports detailing reasons for review, methodology, findings, violations of regulations, and recommendations.
• Participate in evidentiary meetings discussing provider case history, case strategy, and findings to recommend sanctions.
• Testify at administrative hearings and/or trials as a department witness or witness for Managed Care Organizations (MCO).
• Communicate effectively with providers, outside agencies, and consultants regarding recipient restrictions.

Benefits

• Full-time employment with a salary range of $66,250.00 - $100,636.00 annually.
• Opportunity for part-time telework up to 3 days per week.
• Paid holidays and vacation time.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Administration of Human Resource Programs
• Education Level: No Education Listed