Reference #: 4525896 THE POSITION Are you a self-motivated and detail oriented registered nurse? Would you enjoy a career where you have an impact on the quality of care received by Pennsylvania's most vulnerable citizens? The Pennsylvania Department of Health is looking for a Medical Records Examiner to provide quality service to our clients! This position conducts clinical reviews on denials issued by Community HealthChoices (CHC) and Managed Care Organizations (MCO). It also reviews Prior Authorization Review Policies (PARP) submitted by the CHC and MCOs and evaluates emergency medical assistance requests. Consider joining our team and learn about all the wonderful opportunities that a career with the Commonwealth of Pennsylvania can offer you!

DESCRIPTION OF WORK As a Medical Records Examiner, you assist with clinical reviews related to physical health, pharmacy, and long-term services. You examine denials submitted by CHC-MCOs which includes determining if an appropriate denial notice was used, if the denial was handled within the required time frames, if the denial was appropriately denied given the provided justification, and if the appropriate appeal rights was included in the denial notice.

You also assist with reviewing and evaluating prior authorization review process policies submitted by the CHC-MCOs. These reviews include determining whether the policy meets CHC-MCO agreement requirements and if the policy is in line with industry standards. This duty requires acquiring up-to-date knowledge on current medical policies and protocols, and reviewal of policies as needed.

In addition, you assist with reviewing and evaluating medical director reviews related to functional eligibility determination discrepancies. To perform this duty, you must acquire knowledge related to the determination of nursing facility clinically eligible and ineligible regulations. This includes reviewing participant health information and collecting all necessary information required for review.

Interested in learning more? Additional details regarding this position can be found in the position description.

Work Schedule and Additional Information:

Full-time employment, 37.5-hour work week Work hours are 8:00 AM to 4:00 PM, Monday to Friday, with 30-minute lunch. Telework: You may have the opportunity to work from home (telework) part-time up to 5 days a week. In order to telework, you must have a securely configured high-speed internet connection and work from an approved location inside Pennsylvania. If you are unable to telework, you will have the option to report to the headquarters office in Harrisburg. Salary:In some cases, the starting salary may be non-negotiable. You will receive further communication regarding this position via email. Please check your email, including spam/junk folders, for these notices.   REQUIRED EXPERIENCE, TRAINING & ELIGIBILITY QUALIFICATIONS Minimum Experience and Training Requirements: Three years of professional experience in the field of medical assistance, health care services, or human services;or An equivalent combination of experience and training. Special Requirements: All positions require active authorization to practice as a Registered Nurse in Pennsylvania. All employees possessing an active temporary practice permit must obtain licensure as a Registered Nurse within the one (1) year period defined by the Pennsylvania State Board of Nursing. This position requires the employee to possess an active motor vehicle license. Other Requirements: You must meet the PA residency requirement. For more information on ways to meet PA residency requirements, follow the link and click on Residency. You must be able to perform essential job functions. How to Apply: Resumes, cover letters, and similar documents will not be reviewed, and the information contained therein will not be considered for the purposes of determining your eligibility for the position. Information to upport your eligibility for the position must be provided on the application (i.e., relevant, detailed experience/education). If you are claiming education in your answers to the supplemental application questions, you must attach a copy of your college transcripts for your claim to be accepted toward meeting the minimum requirements. Unofficial transcripts are acceptable. Your application must be submitted by the posting closing date. Late applications and other required materials will not be accepted. Failure to comply with the above application requirements may eliminate you from consideration for this position. Veterans: Pennsylvania law (51 Pa. C.S. *7103) provides employment preference for qualified veterans for appointment to many state and local government jobs. To learn more about employment preferences for veterans, go to www.employment.pa.gov/Additional%20Info/Pages/default.aspx and click the Veterans' Preference tab or contact us at ra-cs-vetpreference@pa.gov. Telecommunications Relay Service (TRS): 711 (hearing and speech disabilities or other individuals). If you are contacted for an interview and need accommodations due to a disability, please discuss your request for accommodations with the interviewer in advance of your interview date.

EXAMINATION INFORMATION

Completing the application, including all supplemental questions, serves as your exam for this position. No additional exam is required at a test center (also referred to as a written exam). Your score is based on the detailed information you provide on your application and in response to the supplemental questions. Your score is valid for this specific posting only. You must provide complete and accurate information or: your score may be lower than deserved. you may be disqualified. You may only apply/test once for this posting. Your results will be provided via email.

The Commonwealth is an equal employment opportunity employer and is committed to a diverse workforce. The Commonwealth values inclusion as we seek to recruit, develop, and retain the most qualified people to serve the citizens of Pennsylvania. The Commonwealth does not discriminate on the basis of race, color, religious creed, ancestry, union membership, age, gender, sexual orientation, gender identity or expression, national origin, AIDS or HIV status, disability, or any other categories protected by applicable federal or state law. All diverse candidates are encouraged to apply.