Three years of professional experience with medical assistance, health care services, or human services or any equivalent combination of experience and training. Possession of a current license to practice as a Registered Nurse issued by the Pennsylvania State Board of Nursing; or possession of 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 (1) year period as defined by the Pennsylvania State Board of Nursing.
Role Description
This is work in the review and evaluation of the medical necessity, appropriateness, quality, quantity, adequacy, and compensability of medical care and services rendered by service providers under the Medical Assistance Program. A resource is responsible for the review and evaluation of medical information and examination of medical records and other documentation to assure that eligible medical assistance recipients receive appropriate and quality medical care, that the Medical Assistance Program is properly billed, and that provider and/or recipient fraud and abuse of the Medical Assistance Program is detected and corrected. Work involves the analysis and evaluation of documentation submitted by Medical Assistance Program service providers and generated through PROMISe� in order to make professional medical judgments regarding the appropriate care and services provided to eligible recipients under the Medical Assistance Program. Reviews may be conducted in central office with the Medical Assistance Program service provider furnishing the necessary medical records, on site at the facility, or information may be provided over the telephone for hospital services requiring pre/post admission certification and for any service that may require prior authorization. Work may include serving as a team leader on reviews requiring more than one staff member organizing and coordinating the review process. Resources also provide advisory and consultative services to boards and staff designed to improve the services or administrative procedures in support of medical assistance patients. Judgment and discretion are required in conferring with advisory boards, facility officials, providers, and staffs. Work is performed under the supervision of an administrative superior and is reviewed through conferences and reports.
Possess an active Pennsylvania nursing license. Possess Case Management Society of America recognized certification as a Care/Case Manager, including the Commission for Case Manger Certification, National Academy of Certified Care Mangers, or American Nurses Credentialing Center; or Currently working towards this certification with documented experience with the intent of receiving certification through examination at the next possible date, currently June of 2005. Continued service would be conditional on candidate obtaining certification at said time. Possess a documented work history of two or more years of experience in care management; and possess basic computer skills, including familiarity with Microsoft Office programs.
Role Description
Resource will provide managerial leadership and oversight to project and processes. Resource will be assigned to workgroups and project teams. Assignments will consist of a combination of on-going process responsibilities, standing work group participation and time-limited projects related to the management and operations of all aspects of the Pennsylvania Medicaid program, including but not limited to:
Develop policy and procedure to support a special needs/case management unit based on the Case Management Society of America guidelines
Train staff on the principles of case management and the availability of community and state resources
Develop a listing of community and state resources for use by the case/care manager
Collaborate with other bureaus/contractors which address special needs to assure continuity of services
Maintain oversight of the case management process and assist in developing staff to qualify for case/care manager certification
Collaborate with the Enhanced Primary Care Case Management and disease management vendor as necessary
Evaluation of currents processes and implementation of recommended process improvements
Consult with senior staff to outline major operational issues and develop resolutions based on sound data analysis
Act as liaison between the Department of Public Welfare and external stakeholders (individuals and/or groups)
Assist in determining if any changes should be made to criteria or regulations to better serve their clients
Possess an active Pennsylvania nursing license. Possess a documented work history of five or more years of utilization review experience. Possess a comprehensive knowledge of utilization review processes. Possess experience utilizing criteria sets for review completion. Possess experience with Utilization Review performance monitoring/production standards; and Possess basic computer skills, including familiarity with Microsoft Office programs.
Role Description
Resource will provide managerial leadership and oversight to project and processes. Resource will be assigned to management workgroups and project teams. Assignments will consist of a combination of on-going process responsibilities, standing work group 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, prior authorization and medical review
Evaluation of currents processes and implementation of recommended process improvements
Consult with senior staff to outline major operational issues and develop resolutions based on sound data analysis
Act as liaison between the Department of Public Welfare and external stakeholders (individuals and/or groups)
Assist in the development of in-house training programs related to prior authorization, claims review and processing
Assist in determining if any changes should be made to criteria or regulations to better serve their clients
Provide operational input for claims processing decisions
Interface with Providers having billing / claims problems
Possess an active Pennsylvania nursing license. Possess a documented work history of two or more years of experience with claims review/processing; and Possess basic computer skills, including familiarity with Microsoft Office programs.
Role Description
Resource will provide managerial leadership and oversight to project and processes. Resource will be assigned to management workgroups and project teams. Assignments will consist of a combination of on-going process responsibilities, standing work group 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 currents processes and implementation of recommended process improvements
Consult with senior staff to outline major operational issues and develop resolutions based on sound data analysis
Act as liaison between the Department of Public Welfare and external stakeholders (individuals and/or groups)
Assist in the development of in-house training programs related to claims review and processing
Assist in determining if any changes should be made to criteria or regulations to better serve their clients
Learn and be a resource for how claims process through the PROMISe� system
Assist with coding and procedure code groupings
Provide operational input for claims processing decisions
Interface with Providers having billing / claims problems
Americare enters
into an agreement with State of New Jersey Developmental Centers to provide Physical Therapists through 2011.
Americare Services signs up as sponsor for USA
1359 Team Shifty as they compete in the 2010 J/24 National Championship being held in
Marblehead, MA September 17-19, 2010. The
winner qualifies for the 2011 J/24 World Championship in Argentina.
