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Job Title: Medical Records Content Reviewer
Duration: 6 Months+
Job Descriptions:
Role Description
- This position is located in the Division of Program and Provider Compliance's Practitioner and Recipient Review section of the Bureau of Program Integrity (BPI). The candidate will have an Associate's degree in Health Services Management or two years' experience in healthcare management, preferably outpatient services, and will be responsible for reviewing and evaluating the services provided in the outpatient setting, quality, quantity, compensability and adequacy of documentation to support those services rendered to recipients by providers under the Medical Assistance Program.
Specific duties
- Identifies discrepancies through the analysis of paid claims and various computer reports. This includes but is not limited to analysis of paid claims for patterns identified with high-cost, high-volume providers, and potential cases for review.
- Selects, reviews, analyzes and evaluates cases retrospectively to monitor compliance with State and Federal Regulations. Services are monitored for medical necessity, quality of care and appropriate billing. Verifying services ordered were rendered, and all rendered services were ordered and are appropriate.
- Analyzes for up coding, duplicate billing, unbundling of services and services billed in compliance with Client billing guidance. Uses the ICD-10-CM diagnosis and procedure manuals, coding clinics, CPT and HCPCS manuals, and other related manuals to determine that the paid claim was billed appropriately.
- Prepares case findings, consults with nurse reviewers and prepares preliminary and final letters to providers, researches and utilizes appropriate MA regulations, MA bulletins and Federal Regulations.
- Keeps the section supervisor informed of case development and progress as well as keeps the Bureau's Case Tracking System updated for each active case. Prepares replies to correspondence under the direction of the section's supervisor.
- Functions as case coordinator for assigned cases by planning and conducting retrospective review activities to complete the cases in an efficient/ timely manner.
- Performs in house to verify/assess the documentation of medical care rendered by providers, including the review of medical and fiscal records.
- Coordinates, schedules and participates in teleconferences and meetings when requested by the providers, to include physician consultants, DPW legal counsel, and providers, as applicable, to discuss review processes/case findings.
- Participates in evidentiary meetings with the Section Supervisor/Division Director, in-house medical staff, legal counsel, MCO staff, or other offices/agencies by discussing the provider case history, case strategy, and findings to recommend sanctions in accordance with Department guidelines and to prepare for litigation proceedings.
- Prepares written material during the reviews by writing memoranda, letters, and reports as indicated in order to provide case findings and violations, refer information to other agencies, to communicate with recipients and providers, or to carry out necessary review activities.
- Responds to and assists in tracking complaints from multiple sources including, but not limited to MCO, MA Provider Compliance Hotline, OMAP Tips, website, letters, e-mail and phone.
- Performs other related duties and special projects as assigned by the supervisor in order to meet the goals and objectives of BPI.
Essential Functions
- Knowledge/use of Microsoft Office products and training in Excel
- Communicates effectively, verbal/written
- Prepares correspondence and reports
- Testifies at legal proceedings
- Comprehends & applies rules/regulations
- Completes assignments per procedures
- Establishes and maintains effective work relationships
- Maintains discretion and confidentiality
- Attends trainings, meetings, hearings
- 10. Physically moves materials