Medical Records Examiner

Commonwealth of Pennsylvania
Full Time, Permanent 37.5 per week $61,868 - $93,966 Per year PA Pennsylvania Department of Human Services, 625 Forster St, Harrisburg, PA 17120, United States Apply before 6/5/2024 11:59


Are you a registered nurse who has an Interest in investigating reports of medical program misuse? The Department of Human Services (DHS), Bureau of Program Integrity, is seeking a Medical Records Reviewer to conduct record reviews to detect cases of fraud and abuse rendered by providers under the Pennsylvania Medical Assistance Program. If this sounds like the career you've been looking for, and if you want to help protect the health of your fellow Pennsylvanians, DHS wants to hear from you! Apply today for this exciting opportunity and take your career in a new direction.


In this role, you will act as a case coordinator and review, as well as evaluate, the medical necessity, appropriateness, and adequacy of care and identify discrepancies through the analysis of paid claims, itemized bills, computer reports, medical records, diagnosis coding, and other information. This includes retrospective cases. You will prepare case findings and consult with in-house medical staff to write the necessary letters to providers. You will also prepare other material in the course of the review by writing memoranda, letters, and reports to make case status changes, refer information to other agencies to communicate with providers or carry out necessary review activities. You will participate in meetings with the division director, section supervisor, legal counsel, and other agencies. At these meetings, you will discuss the provider case history, case strategy, and your findings to recommend sanctions in accordance with department guidelines, and to prepare for testifying at administrative hearings or trials in Commonwealth or Federal Court.

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

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 30-minute lunch.
  • Telework: You may have the opportunity to work from home (telework) part-time up to 3 days a week. In order to telework, you must have a securely configured high-speed internet connection and work from an approved location inside Pennsylvania. If you are unable to telework, you will have the option to report to the headquarters office in Harrisburg.
  • 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.