Medical Services Reviewing Nurse II

The primary purpose of this position is to

A. Perform data mining and analyze Medicaid claims to identify billing irregularities and identify provider billing outliers, in an effort to identify bad providers and reduce fraud, waste and abuse against the Maryland Medicaid Program. B. Plan and conduct reviews of Medicaid provider billings with emphasis on medical coding investigations, searching for overbilling by using highest reimbursement codes (upcoding), unbundling of medical procedure codes, and billings using medical codes that don’t match type of provider or type of services rendered. C. Plan and conduct investigations of Medicaid providers to include reviewing their claims universe, selecting audit samples, identifying risks, developing audit workplans, planning and executing onsite provider visits to interview billing staff, collect and scan documents, executing audit steps, developing audit findings and writing audit reports to include findings and recommendations.

D. Guide, oversee, and assist staff with workplans, and review staff's investigations, workpapers, and reports. E. Ensure provider billings are in compliance with COMARs and other State and Federal regulations. F. Supervise any vendors hired to perform statistical extrapolations or clinical reviews of services and serve as contract monitor for any contracts executed for these services.

G. Assist OIGH certified coders in assessing medical necessity, clinical appropriateness, or other medical aspects of billed services. H. Assist OIGH certified coders in assessing medical necessity, clinical appropriateness, or other medical aspects of billed services.

This position will utilize specialized nursing knowledge, medical coding knowledge, certifications and extensive experience in Current Procedural Terminology coding (CPT), Internal Classification of Disease coding (ICD-10), and Healthcare Common Procedure Coding (HCPCS), coding conventions, as well as general billing experience. This position will also utilize required knowledge and experience in nursing and supervision, as well as knowledge of State and federal regulations along with thorough comprehension of medical and surgical terminology is essential in order to make definitive decisions as they pertain to regulatory compliance.

Minimum qualifications

Education

A Bachelor’s degree in Nursing or a related field from an accredited college or university.

Experience

One year of experience reviewing medical services claims to ensure that the nature and quality of services are in accordance with State and federal regulations.

Notes

• Candidates may substitute two years of experience as a Registered Nurse for the required education.

• Candidates may substitute U. S. Armed Forces military service experience as a commissioned officer in Nursing classifications or Nursing specialty codes in the Nursing field of work on a year-for-year basis for the required education.

Desired OR preferred qualifications

The desired candidate should possess the following

Experience with healthcare fraud, waste, and abuse detection, including identifying billing irregularities, documentation deficiencies, and potential fraudulent schemes. Experience conducting clinical record analysis and preparing clear, concise written summaries, reports, and case documentation. Experience explaining complex clinical findings to non-clinical audiences. Experience providing testimony, participating in administrative hearings, or supporting legal or administrative enforcement actions.

Licenses, registrations and certifications

• Candidates for positions in this classification must possess a current license as a Registered Nurse from the Maryland State Board of Nursing, 4140 Patterson Avenue, Baltimore, Maryland 21215 or possess a current multi-state license in party states that candidates have declared as primary states of residence.

• Employees in this classification may be assigned duties which require the operation of a motor vehicle. Employees assigned such duties will be required to possess a motor vehicle operator’s license valid in the State of Maryland.

Selection process

Applicants who meet the minimum (and selective) qualifications will be included in further evaluation. The evaluation may be a rating of your application based on your education, training and experience as they relate to the requirements of the position. Therefore, it is essential that you provide complete and accurate information on your application.

Please report all related education, experience, dates and hours of work. Clearly indicate your college degree and major on your application, if applicable. For education obtained outside the U. S., any job offer will be contingent on the candidate providing an evaluation for equivalency by a foreign credential evaluation service prior to starting employment (and may be requested prior to interview).

Complete applications must be submitted by the closing date. Information submitted after this date will not be added.

Incorrect application forms will not be accepted. Resumes will not be accepted in lieu of a completed application.

Candidates may remain on the certified eligible list for a period of at least one year. The resulting certified eligible list for this recruitment may be used for similar positions in this or other State agencies.

Benefits

State of maryland benefits

Further instructions

Online applications are highly recommended. However, if you are unable to apply online, the paper application (and supplemental questionnaire) may be submitted to MDH, Recruitment and Selection Division, 201 W. Preston St., Room 114-B, Baltimore, MD 21201. Paper application materials must be received by 5 pm, close of business, on the closing date for the recruitment, no postmarks will be accepted.

If additional information is required, the preferred method is to upload. If you are unable to upload, please fax the requested information to 410-333-5689. Only additional materials that are required will be accepted for this recruitment. All additional information must be received by the closing date and time.

For questions regarding this recruitment, please contact the MDH Recruitment and Selection Division at 410-767-1251.

If you are having difficulty with your user account or have general questions about the online application system, please contact the MD Department of Budget and Management, Recruitment and Examination Division at 410-767-4850 or Application. Help@maryland.gov.

Appropriate accommodations for individuals with disabilities are available upon request by calling: 410-767-1251 or MD TTY Relay Service 1-800-735-2258.

We thank our Veterans for their service to our country.

People with disabilities and bilingual candidates are encouraged to apply.

As an equal opportunity employer, Maryland is committed to recruitment, retaining and promoting employees who are reflective of the State's diversity.