| Job Description : |
MAJOR POSITION DUTIES AND RESPONSIBILITIES:
These positions will support the Office of Long Term Living (OLTL) Home and Community Based Services (HCBS) Providers’ Quality Improvement Grant Program through the approval or denial review process of provider grant applications.
This provider grant opportunity is focused on supplementing activities that would promote and strengthen the coordination of services by affording providers the opportunity to improve their ability to track quality measures and associated outcomes more accurately. The grants awarded are based on individual provider applications which are funded through the ARPA funding provided to the State of Pennsylvania.
Maintains a working knowledge of Medical Assistance regulations including but not limited to 55 PA Code Chapters 52, 1101, 1150, 1187, and 1189 governing Nursing Facilities and HCBS Waiver Providers.
Answers calls from nursing facilities or waiver providers via the Office of Long-Term Living (OLTL) Provider Toll Free Inquiry Line. This duty requires extensive knowledge of Medical Assistance regulations, policies, and billing procedures. Must be able to provide instruction to providers on how to correct billing errors.
Must have the ability to effectively communicate information to others.
Responds to phone calls, emails, and other correspondence from providers, representatives, and other stakeholders. This requires extensive knowledge of regulations, policies and procedures, and the ability to provide instruction to providers on how to complete claim resolution and processing accurately.
Review and process exception requests submitted in accordance with the 180-day billing requirements. Reviews require the ability to independently make determinations to approve/deny claims based on the 180-day billing requirements.
Prepare correspondence for providers who have requested 180-day exceptions to inform providers of approval, denial, or the need for further documentation to decide.
Determine whether claims should be submitted for special handling to the claims processing contractor and the proper method of preparation.
Responsible for reviewing and processing suspended claims in PROMISe and ensuring that this is done timely and accurately to meet the Prompt Pay Provisions.
Represents the Department via telephone and/or face-to-face hearings through the Bureau of Hearings and Appeals in order to defend decisions of denial as dictated by Medical Assistance regulations for any claims which are appealed by providers.
Review, prepare, enter, and track additional gross adjustments as necessary.
Maintains appropriate databases for data input, research, analysis, updating, and reporting purposes.
Responsible for reviewing failed provider payments and determining if a reissuance is the best course of action.
Responsible for entering debit and credit gross adjustments for provider payments and recoupment efforts.
Performs other related duties as required.
About Us:
TulaRay partners with clients to create staffing solutions that meet unique organizational needs. Our services are designed to reduce administrative burdens, protect your brand, and improve assignment time-to-fill. We believe that mutually successful client relationships are built on lasting quality and exceptional customer service. We pride ourselves on our uncompromising commitment to high-quality emergency management & healthcare personnel, while ensuring that our clients are taken care of with personalized attention. TulaRay manages total compliance and respectfully supports hundreds of professionals and patient-centered programs.
TulaRay is proud to be an affirmative action employer and is committed to providing equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you have a disability or special need that requires accommodation, please let us know by visiting our website at tularay.com |
