POSITION ROLE AND RESPONSIBILITIES
- Provide utilization and quality reviews and provide clinical input into projects as directed by the Department.
- Review all documents relevant to the type of assignment given, including but not limited to: History and physicals; Physician orders; Plan of care/treatment plans; Progress notes; Laboratory studies; X-rays; Physician consultation reports; Surgical operative reports; Diagnostic tests; Death certificates; Medications; Nurses notes; Therapy evaluations; Discharge summaries; All reviews will be completed within the time frames specified in advance by the Department.
- Depending on the type of case reviewed, required to compile findings, prepare summaries, and make recommendations for case disposition in language understandable by the recipient when applicable, conduct peer-to-peer telephone calls, prepare appealed cases for hearings, and be available to testify at hearings for cases under appeal by phone, video, or face to face.
- Assist in the development of in-house training programs, medical necessity criteria, and quality of care indicators.
- Review established criteria for consistency among plans serving Medical Assistance recipients throughout the state.
- May assist to determine changes made to guidelines, criteria, or regulations, to better serve recipients.
- Participate in new Technology Assessments.
- Participate in all Bureau employee mandated training including, but not limited to, HIPAA compliance and Security training.
- May be required to represent the Department at face-to-face hearings or telephone hearings for cases that they have reviewed that are under appeal. On an infrequent basis, travel may be required to participate in face-to-face hearings in state office buildings in cities across Pennsylvania. Reimbursement for travel required by the Department will be made in accordance with travel regulations.
- Be board certified in a Primary Care Specialty
- Possess an active Pennsylvania Medical License
- If feasible, be active in clinical practice in the area in which the consultant is board certified at least sixteen (16) hours per month
- Demonstrate an understanding of utilization review process
- Possess basic computer skills, including familiarity with Microsoft Office programs
Prior to beginning work, required to supply the following credentials:
- Copy of Pennsylvania Medical License
- Copy of DEA Certification if applicable
- Copy of any applicable Board Certification
- Verification of ongoing clinical practice if applicable
- Verification of continuing medical education including dates and credits earned for each educational session
- Attestation that no prohibitions, sanctions, or terminations have been levied on Consultant from Federal, State, or other health programs in and outside of Pennsylvania
- Verification of malpractice insurance, if insurance is not provided by Vendor
- Documentation of any malpractice actions or settlements during the past year
We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.