Description of Work/Duties:

Consultant will work with the Department of Human Services, Office of Medical Assistance Programs (OMAP), BFFSP.

Consultant will:

Be available as a consultant on average 37.5 hours per week;

Possess a bachelor’s degree, certification or documented work history of two or more years of work experience performing provider relations regarding billing, researching claims and call center experience.

Possess strong computer skills including familiarity with Microsoft Office programs.

Consultant will provide leadership, oversight and support for assigned projects and processes, for the BFFSP, Division of Operations. Consultant may be assigned to represent BFFSP and the Division on workgroups and project teams. Assignments may consist of a combination of on-going process responsibilities, standing work group participation and time-limited projects related to the management and operations of all aspects of the Pennsylvania Medicaid program, including but not limited to:

Develop utilization-specific reporting, to identify access patterns, practice styles, accessibility, and configuration of medical services.

Provide lead staff support in the Provider Service Center (PSC), ensuring courteous, professional, high-quality performance of PSC operations, support the design and implementation of proactive Provider Relations processes, including provider education and network development.

Evaluation and implementation of system enhancements for service delivery (including development of RFP’s), provider inquiry, 180-Day and Electronic Visit Verifications.

Analysis of Delinquent Accounts, and billing inquires.

Evaluation of current operational processes and implementation of recommended process improvements.

Act as liaison between the BFFSP and external stakeholder (individuals and or groups).

Assist in the development of in-house training materials related to the Division of Operations.

Develop and implement project tracking system for complicated issues requiring department research and follow up

Supports the BFFSP Correspondence Tracking System (CTS) Liaison, at the Liaison’s direction, with monitoring CTS for new assignments, logging and distributing assignment to be completed by BFFSP staff. Ensures assignments are completed by deadlines by following up as required. Maintains working relationships with OMAP Deputy Secretary’s office as well as other OMAP agencies.

Consultant will report to their designated supervisor in the Division of Operations. Assignments will be received verbally or in writing and will be carried out independently with minimal direct supervision. Work will be overseen through weekly or biweekly status meetings with Division management.

Consultant, when requested, will work at one or more of the Department's work sites. Consultant’s primary work station will be at the Commonwealth Towers, Harrisburg. Consultant will be provided with a desk, computer, phone, and all items necessary for him/her to complete assignments.

If Consultant is unable to appear at the scheduled work site at the pre-determined times, notification must be made to the designated Supervisor either prior to date or on date of absence, in accord with the established BFFSP procedures.

Consultant may be required to represent the BFFSP or Division at activities off-site from the primary work station and/or outside of Harrisburg. Reimbursement for travel required by the Department, will be made in accordance with the Commonwealth of Pennsylvania’s travel regulations. 

Work Product Deliverables

Verbal or written assignments for on-going processes, standing work groups and projects will include specific and detailed descriptions of deliverables including nature of the work product, expected timeframes, available resources and desired outcomes. Progress towards interim goals and deliverables will be assessed during regular status meetings with the designated supervisor.

Quality of work product;

Appropriateness of work habits;

Growth of knowledge base and skill set;

Effectiveness of communications;

Initiative and problem-solving skills;

Contributions to a productive and hospitable work environment;

Effectiveness in oversight;

Effectiveness in external liaison activities; and Consultant’s evaluation of OMAP work environment and quality of supervision/direction.

Many factors in the current environment make Medical Assistance (MA) extremely complicated and time-consuming, and as a result, the Commonwealth of Pennsylvania, Department of Human Services (DHS), Office of Medical Assistance Programs (OMAP) sought to establish a comprehensive call center for Medical Assistance providers and Medical Assistance Recipients. In doing so, the Bureau of Fee-for-Service Programs (BFFSP) established the Provider Service Center (PSC) and the Recipients Service Center (RSC), which is staffed with both internal staff and vendor outsourcing services. The PSC and RSC are call centers for providers and receipients to obtain real-time, live help on their billing issues, claims inquiries, eligibility problems, and any other issues. Also within the Bureau of Operations we house our Delinquent Account Resolution (DAR) unit which idenfies outstanding balance owed to the Commonwealth and attempts to collects the debts. The 180 day exception unit reviews untimely claims submitted for payment and determines if the claims meet the exception criteria. Last within Operations we have the Dental Unit which review dental request for autorization for services and assist with billing dental claims. Operations is staffed Monday-Friday, from 8:00 am to 4:30 pm, by state employees and contracted Program Specialists and Lead Medical Assistants.

The mission of the unit is to provide timely, accurate, and friendly responses to inquiries with the objective of ultimately reducing inquiries through provider education and timely solutions.

• Complete intensive Pennsylvania Medical Assistance training program covering all aspects of claims processing, medical billing, various system functionality, policy, recipient and provider eligibility, prior authorization, and various other topics relevant to the Medical Assistance provider and recipient communities
• Respond to, analyze, and resolve incoming inquiries from Pennsylvania Medical Assistance provider community related to claims submission/processing/payment/status, procedure codes, prior authorizations, NPI, provider and recipient eligibility, system issues, and numerous other Medical Assistance related items
• Adhere to Industry Standard Call Center performance measures
• Abide by Information Technology, Commonwealth, and HIPAA rules and regulations
• Provide assistance with answering calls for the PSC and RSC lines
• Analyze reports and metrics to monitor staff production
• Research 180-day requests to determine eligibility for exception
• Work on 180-day electronic implementation work groups
• Compile quarterly 180 data for FFS Subcommittee
• Schedule quarterly FFS Subcommittee meeting
• Submit Sunshine notices for FFS Subcommittee meetings
• Compile agenda and PowerPoint for FFS Subcommittee meetings
• Filter DAR’s monthly spread sheet for current receivables
• Negotiate outstanding settlement agreements with the provider community
• Research outstanding debit for possible documentation of closure, selling of the practice etc. to determine if the debit can be paid off or written off
• Back-up for state staff in the Dental Unit learning the authorization and claims processing for Dental Providers
• Retrieving records for record releases and records in conjunction with Right to Know Law Request
• Distributing and tracking request received in the Correspondence Tracker
• Documents staff working in the office
• Works on improving processes with recipient billing issues and work flow tracking
• Maintains updated provider lists for the RSC line
• Works as the HIPAA coordinator for the Bureau by sending out the mandatory training and tracking completion.
• Assist with Physical Health provider billing appeals
• Works extensively in Microsoft Office
• Assist with IT/software trouble shooting
• Works on special project

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