Medical Records Examiner

Are you a detail-oriented registered nurse committed to ensuring high-quality care for Pennsylvania's most vulnerable residents? The Department of Human Services is seeking a dynamic and enthusiastic Medical Records Examiner with a strong work ethic to join our Office of Long-Term Living (OLTL). In this important role, you will conduct clinical reviews and evaluate service denials as part of the Clinical Review Team, helping to safeguard care quality and uphold program integrity. If you are eager to take on new challenges, expand your expertise, and make a meaningful impact through your clinical knowledge and analytical skills, we encourage you to apply and advance your professional career!

In this position, you will support clinical reviews of denials related to physical health services, pharmacy benefits, and long-term services and supports. Your responsibilities include evaluating whether appropriate denial notices were issued, required timelines were met, determinations were supported by the available documentation, and appeal rights were clearly and accurately communicated. You will assist the OLTL Medical Director in reviewing Medical Director determinations involving discrepancies between Functional Eligibility Determinations and physician certifications. In this work, you will develop a strong understanding of nursing facility clinical eligibility and ineligibility criteria, thoroughly review participant health records, and compile all necessary documentation to ensure comprehensive and accurate evaluations. In addition, you will support the review and assessment of the Licensed Proprietary Products (LPP) annual report, helping to ensure that LPPs remain clinically sound, operationally appropriate, current in practice, and aligned with nationally recognized standards of care.

Interested in learning more? Additional details regarding this position can be found in the position description.

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.

• This position is home headquartered. In order to be home headquartered, you must have a securely configured high-speed internet connection and work from an approved location inside Pennsylvania.

• 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:

Other Requirements:

• You must meet the PA residency requirement. For more information on ways to meet PA residency requirements, follow the link and click on Residency.
• 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.