Paxtonia, PA

Short Description:

Advanced level - The resource can perform the actions associated with this skill without assistance. Resource is certainly recognized within its immediate organization as a person to ask when difficult questions arise regarding this skill.

Complete Description:

Minimum Qualifications

ò BachelorÆs degree or equivalent.

ò Significant experience managing input and manipulation of information using information systems and data management software.

ò Basic computer skills, including proficiency with Microsoft Office products (Word, Excel, PowerPoint, Outlook, etc.).

Role Description

ò This full-time, on-site position serves as a liaison between the contractor and the departmentÆs staff, supporting the development and implementation of various Information Systems as part of the contractorÆs Clinical Information System development and support team.

ò Key Responsibilities:

ò Perform ongoing technical maintenance of the BureauÆs Quality Management Program, including its implementation.

ò Coordinate data entry into multiple information systems.

ò Analyze information and generate reports from these systems to support the Quality Management Program.

ò Act as a liaison with the contractorÆs Clinical Information System development and support team.

ò Maintain and upgrade professional skills by attending meetings, training sessions, and seminars, as well as reviewing current literature.

Below WOS Attachement.  

QUALITY IMPROVEMENT INFORMATION SPECIALIST WORK STATEMENT  

This position is in the Integrity Management Section, Data and Financial Reporting Unit of the Bureau of Program Integrity (BPI), Office of Administration, within the Commonwealth of Pennsylvania’s Department of Human Services.

The contractor must be available full-time 37.5 hours per week, 8:00 am-4:30 pm (with hour lunch) or 8:00 am-4:00 pm (with half an hour lunch) and will be provided with a desk, computer, phone, and all items necessary for him/her to complete assignments.

If the contractor is required to travel on behalf of the Department, advance notice will be provided of the need to travel.  Reimbursement for travel required by the Department will be made in accordance with the CWOPA travel regulations.  Travel to and from the designated work site is considered commuting and does not qualify for mileage reimbursement.

This support position is responsible for the following functions:  

• Triages fraud and abuse referrals to the Bureau, including data investigation, documenting preliminary findings, and forwarding to appropriate Bureau sections for further action. These referrals can come from a variety of sources, via RA inboxes, direct emails, or hard copy mail/faxes.
• Triages calls from the DHS Tips hotline; including returning calls for more information and referring to areas in and outside of the Bureau for further action.
• Completes balance billing referrals/cases, including calls/emails/letters to providers, tracking of cases and following up with recipients as to the status of the case
• Represents the Bureau in the resolution of any issues occurring with any of the job functions listed.
• Assists with data analysis and support to other Bureau staff by:
  • Identifies discrepancies through the analysis of paid claims, time sheets, and computer reports through the Fraud Abuse Detection System which is known as FADS.  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.  Verifying services ordered were rendered, and all rendered services were ordered and are appropriate.
  • Functions as case coordinator for assigned cases by planning and conducting retrospective review activities to complete the cases in an efficient/timely manner.
  • Prepares written material in the course of 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.
• Right to Know Law coordination and response as needed.
• Assist with internal audit coordination and response as needed.
• Single claim adjustments entry and resolution as needed.
• Gross adjustment entries and resolution as needed.
• Tracking claim and gross adjustment entries as needed.
• Monthly and ad-hoc recovery reporting to each Bureau Section Supervisor and Executive Management staff as tracked in the Claims Adjustment and Gross Adjustment Data Base as needed.
• Travels to perform required duties as required.
• Performs any other related duties as directed by the Section Supervisor.

Skills Required:  

• Basic medical claims knowledge
• Knowledge of CPT, HCPC, ICD-9 National Codes sets
• Familiarity with medical terminology
• Works independently.
• PC knowledge in Windows environment

o Microsoft Word

o Microsoft Outlook

o Microsoft Excel

o Microsoft Access

• Data entry skills
• Mathematical aptitude
• Strong organizational skills
• Ability to prioritize and manage work flow
• Ability to meet deadlines and maintain Bureau quality standards
• Attention to detail
• Ability to get along well with others and work in a team environment
• Maintain professional client relationships
• Strong customer service skills
• Excellent written and oral communication skills
• Ability to quickly learn new concepts and apply them in work assignments
• Data analysis or data warehousing knowledge preferred

On a weekly basis, the contractor will complete time sheets and the work site supervisor will verify and approve them.  The contractor will be responsible for forwarding all approved/signed sheets to the vendor. 

Payment to the vendor will be made after services are actually rendered by the contractor.  If the contractor is unable to appear at the scheduled work site at the pre-determined times, notification must be made to the on-site contract manager or on-site supervisor either prior to the date or on the date of absence.

Quality Improvement Information Specialist Work Statement - Page 2

The contractor acknowledges that, in performing contractor services, he/she will be made privy to information of a confidential nature, including but not limited to information regarding the medical history of a client.  The contractor hereby covenants to maintain the confidentiality of all such information, to the extent required by law and medical ethics.  The contractor shall only disclose such confidential information to other medical experts to the extent necessary to provide the contractor services contemplated herein and only after prior notice to the Department of intent to so disclose.

The vendor will submit invoices to the following address:

                                           Commonwealth of Pennsylvania – PO Invoices

                                           P.O. Box 69180

                                           Harrisburg, PA  17106 …