Medical Records Examiner

Are you looking to utilize your nursing expertise and professional judgment in a new and rewarding career path? The Department of Human Services (DHS) is seeking a dynamic and detail-oriented Medical Records Examiner to join our dedicated Division of Program and Provider Compliance team. In this key role, you will be responsible for conducting site reviews to detect cases of fraud and abuse rendered by providers under the Pennsylvania Medical Assistance Program. If you are eager to tackle new challenges and build on your current knowledge while protecting the health of your fellow Pennsylvanians, then this position is perfect for you. Apply today!

As a Medical Records Examiner, you will review records, documents, and claims submitted by enrolled Medical Assistance (MA) providers. You will evaluate and determine if services provided to eligible beneficiaries of the MA Program were medically necessary and billed in accordance with MA regulations and other state and federal requirements. This will include:

• Reviewing provider medical records and claims history
• Processing referrals for potential fraud, waste, and abuse within the Medicaid provider system
• Utilizing case tracking, preparing cases, and reporting findings to providers
• Communicating with providers, outside agencies, and consultants
• Testifying at administrative hearings or trials in Commonwealth or federal court

Work Schedule and Additional Information:

• Full-time employment, 37.5 hours per week
• Work hours are 8:00 AM to 4:00 PM, Monday - Friday, with a 30-minute lunch.
• Free parking
• Telework: You may have the opportunity to work from home (telework) part-time, up to three days per week. In order to telework, you must have a securely configured high-speed internet connection and work from an approved location inside Pennsylvania. If you are unable to telework, you will have the option to report to the headquarters office in Harrisburg, PA. The ability to telework is subject to change at any time. Additional details may be provided during the interview.
• Salary: In some cases, the starting salary may be non-negotiable.
• You will receive further communication regarding this position via email. Check your email, including spam/junk folders, for these notices.

QUALIFICATIONS

Minimum Experience and Training Requirements:

• Three years of professional experience in the field of medical assistance, health care services, or human services; or
• An equivalent combination of experience and training.

Special Requirements:

• You must possess active authorization to practice as a Registered Nurse in Pennsylvania.
• All employees possessing an active temporary practice permit must obtain licensure as a Registered Nurse within the one (1) year period defined by the Pennsylvania State Board of Nursing.
• You must be in possession of an active motor vehicle license.

• You must meet the PA residency requirement. For more information on ways to meet PA residency requirements, follow the link and click on Residency Guidelines.
• You must be able to perform essential job functions.

How to Apply:

• Resumes, cover letters, and similar documents will not be reviewed, and the information contained therein will not be considered for the purposes of determining your eligibility for the position. Information to support your eligibility for the position must be provided on the application (i.e., relevant, detailed experience/education).
• If you are claiming education in your answers to the supplemental application questions, you must attach a copy of your college transcripts for your claim to be accepted toward meeting the minimum requirements. Unofficial transcripts are acceptable.
• Your application must be submitted by the posting closing date. Late applications and other required materials will not be accepted.
• Failure to comply with the above application requirements may eliminate you from consideration for this position.

Veterans:

Telecommunications Relay Service (TRS):

If you are contacted for an interview and need accommodations due to a disability, please discuss your request for accommodations with the interviewer in advance of your interview date.

The Commonwealth is an equal employment opportunity employer and is committed to a diverse workforce. The Commonwealth values inclusion as we seek to recruit, develop, and retain the most qualified people to serve the citizens of Pennsylvania. The Commonwealth does not discriminate on the basis of race, color, religious creed, ancestry, union membership, age, gender, sexual orientation, gender identity or expression, national origin, AIDS or HIV status, disability, or any other categories protected by applicable federal or state law. All diverse candidates are encouraged to apply.

• Completing the application, including all supplemental questions, serves as your exam for this position. No additional exam is required at a test center (also referred to as a written exam).
• Your score is based on the detailed information you provide on your application and in response to the supplemental questions.
• Your score is valid for this specific posting only.
• You must provide complete and accurate information or:
  • your score may be lower than deserved.
  • you may be disqualified.
• You may only apply/test once for this posting.
• Your results will be provided via email.