InGenesis Claims Review Management RN in Harrisburg, Pennsylvania

Claims Review Management Nurse to provide services for the Commonwealth of Pennsylvania

Harrisburg, PA

Must have medical coding experience. This position is professional work in the review and evaluation of procedure coding including the Health Care Common Procedural Coding System (HCPCS), Current Procedural Terminology (CPT) and other coding set and editing information related to Medical Assistance (MA) fee schedules and claims processing system. Work may involve the review and evaluation of medical necessity, appropriateness, quality, quantity, adequacy, and compensability of medical care and services rendered by MA service providers.


Responsible for the review, evaluation and implementation of coding set updates, related systems enhancements, current process and implementation of recommended process improvements.

Knowledge of the more common medical diagnoses and the associated treatments and services provided in relation to these diagnoses.

Assignments will consist of a combination of on-going responsibilities, standing work group participation and time limited projects related to the management and operations of all aspects of the Pennsylvania Medicaid program.

Knowledge of procedural coding such as HCPCS, CPT, and other coding sets related to MA

Knowledge of policies and regulations.


Possession of a current license to practice as a Registered Nurse by the Pennsylvania State Board of Nursing; or

Possession of a non-renewable temporary practice permit issued by the Pennsylvania State Board of Nursing. Candidates possessing non-renewable temporary practice permits must obtain licensure as a Registered Nurse within the one year period as defined by the Pennsylvania State Board of Nursing.

Proficient writing and basic computer skills to include, but not limited to, Microsoft Office Products.

Three years of professional experience with Medical assistance (MA), health care services, or human services.

Minimum of three years of recent (within the last five years) professional experience medical-surgical, rehabilitation, or quality management/utilization review and other related clinical experience.

Knowledge of and familiarity with the following would be beneficial: Inter-Qual criteria, ICD-9 CM, and current procedure terminology.

Ability to use professional judgment in identifying aberrant patterns and determining the appropriate action to be taken following the documentation review.

InGenesis provides healthcare management and staffing solutions to government, education and corporate clients and is one of America's fastest-growing independent companies. InGenesis is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin.