Medical Record Review Registered Nurse

Job Title: Medical Record Review Registered Nurse

Dutation: Contract (12+ Months)

Work Arrangement: Hybrid

Shift: 7:30 AM - 4:00 PM

Description: 

• Be available as a full-time consultant, approximately 37.5 hours per week;
• Possess an active Pennsylvania Registered Nurse license;
• Possess a documented work history of five (5) or more years of experience with claims review/coding or processing; be familiar with HCPCS II, CPT, or Dental coding;
• Possess computer skills, including familiarity with Microsoft Office programs, including Microsoft Excel/Word/PowerPoint;
• Possess prior experience with PROMISe or similar claims processing system;
• Possess prior experience with Medicare or Medical Assistance coding rules;
• Possess prior experience with researching medical policies, out of state comparison, participation in studies or projects.

Responsibilities: 

• Provide oversight to projects and processes for support of managerial leadership. Consultant will be assigned to workgroups and project teams. Assignments will consist of a combination of ongoing process responsibilities, standing workgroup participation, and time-limited projects related to the management and operations of all aspects of the Pennsylvania Medicaid program, including but not limited to:
• Evaluation and implementation of system enhancements for provider enrollment, provider inquiry, and medical review;
• Evaluation of current processes and implementation of recommended process improvement;
• Consult with senior staff to outline major operational issues and develop resolutions based on sound data analysis;
• Act as a liaison between the Client and external stakeholders (individuals and/or groups);
• Assist in determining if any changes should be made to criteria or regulations to better serve clients;
• Review certain claims, analyze, and process through the payment system;
• Provide operational input for claims processing decisions;
• Assist with coding and procedure code groupings;
• Participate in the yearly coding updates and assist in updating the system according to the reviewed and accepted codes for the PA Medical Assistance Program;
• Perform other related duties as assigned by the managerial staff;
• Consultant will report to the state supervisor staff. Assignments will be received verbally or in writing, and will be carried out independently with minimal direct supervision;
• 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.

• Provide oversight to projects and processes for support of managerial leadership. Consultant will be assigned to workgroups and project teams.
• Assignments will consist of a combination of ongoing process responsibilities, standing workgroup participation, and time-limited projects related to the management and operations of all aspects of the Pennsylvania
• Medicaid program, including but not limited to:
• Evaluation and implementation of system enhancements for provider enrollment, provider inquiry, and medical review;
• Evaluation of current processes and implementation of recommended process improvement;
• Consult with senior staff to outline major operational issues and develop resolutions based on sound data analysis;
• Act as a liaison between the Client and external stakeholders (individuals and/or groups);
• Assist in determining if any changes should be made to criteria or regulations to better serve clients;
• Review certain claims, analyze, and process through the payment system;
• Provide operational input for claims processing decisions;
• Assist with coding and procedure code groupings;
• Participate in the yearly coding updates and assist in updating the system according to the reviewed and accepted codes for the PA Medical Assistance Program;
• Perform other related duties as assigned by the managerial staff;
  Consultant will report to the state supervisor staff. Assignments will be received verbally or in writing, and will be carried out independently with minimal direct supervision;
• 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.