Hybrid MDS Registered Nurse
Harrisburg, PA US
Hybrid MDS Registered Nurse
Looking for a Nurse to work in the review and evaluation of the medical necessity, appropriateness, quality, quantity, and adequacy of medical care and services rendered by service providers. 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.
Location: Remote after 6-8 weeks of training in Harrisburg, on site travel may be required (not regularly), must work from the office 1 day per week
Hours: Monday - Friday / 8a – 4pm (30 min lunch)
Pay: 32.00 hourly
RN Auditor Requirements:
- Current license to practice as a Registered Nurse from the Pennsylvania State Board of Nursing
- Proficient Computer Skills including Microsoft Word, Excel, Outlook and Teams
- 3+ years of experience in one or more of the following areas as related to the position need: long term care, acute care setting, behavioral health setting, drug and alcohol setting, managed care, quality management/utilization review or other related clinical experience
- Ability to use professional judgment in identifying aberrant patterns and determining the appropriate action to be taken following the documentation review.
- Preferred: Knowledge of Inter- Qual criteria, ICD-9 CM, MDS and current procedure terminology
RN Registered Nurse Full Details:
- Identify discrepancies through analysis of computer reports, claims history profiles, MCO encounter data, other documents and referrals/complaints in order to select MCO participating providers for review of compliance with program regulations and other state/federal requirements.
- Function as case coordinator for assigned cases by planning and conducting retrospective review activities to complete the case in an efficient/ timely manner.
- Perform in house and on-site reviews and recipient interviews to verify/assess the medical care rendered by providers, including the review of medical and fiscal records, MCO documentation, and MCO policy and payment information.
- Coordinate, schedule and participate in teleconferences and meetings when requested by the provider, to include physician consultant, DPW legal counsel, MCOs and provider, as applicable, to discuss review processes/case findings.
- Participate 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.
- Prepare written material in the course of the reviews by writing memoranda, letters, and reports as indicated in order to provide care findings and violations, refer information to other agencies, to communicate with recipients and providers, or to carry out necessary review activities.
- Respond to complaints from multiple sources including, but not limited to MCO, MA Provider Compliance Hotline, Tips web site, 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.
Registered Nurse Auditor Essential Functions:
- Knowledge/use of Microsoft Office products
- Communicate effectively, verbal/written
- Prepare correspondence and reports
- Testify at legal proceedings
- Comprehend & apply rules/regulations
- Complete assignments per procedures
- Establish and maintain effective work relationships
- Maintain discretion and confidentiality
- Travel and attend on-site visits, trainings, meetings, hearings
- Physically move materials
MDS, Skilled Nursing, LTC, Long Term Care, Assisted Living, AL Facility, SNF, Registered Nurse, Auditing, Auditor, medical necessity review, patient safety, care management, case management