State of Maryland

A Medical Services Reviewing Nurse Supervisor is the supervisory level of work reviewing medical assistance or compensation claims to ensure that the medical services provided are of a nature and quality that is consistent with State and federal regulations. These employees also conduct reviews to guard against fraud and abuse.  Employees in this classification supervise lower-level Medical Services Reviewing Nurses and other professional and nonprofessional support staff.

Employees in this classification receive general supervision from a higher-level health administrator.

Positions in this classification are evaluated by using the classification job evaluation methodology.  The use of this method involves comparing the assigned duties and responsibilities of a position to the job criteria found in the Nature of Work and Examples of Work sections of the class specification.

The Medical Services Reviewing Nurse Supervisor is differentiated from the Medical Services Reviewing Nurse II in that the Medical Services Reviewing Nurse Supervisor has supervisory responsibility for lower-level Medical Services Reviewing Nurses, while the Medical Services Reviewing Nurse II performs the full range of duties and responsibilities under general supervision.

Supervises Medical Services Reviewing Nurses and other professional and nonprofessional support staff;

Administers a specific program, such as monitoring the activities of a privately contracted Utilization Control Agent;

Reviews medical assistance claims from physicians and other health care providers to ensure consistency with State and federal regulations and that medical treatment is correct and necessary;

Reviews patient medical histories to determine possible misuse of medical assistance funds;

Investigates complaints from recipients and other agencies to determine the need for corrective action;

Documents all findings and recommendations of reviews and investigations;

Provides information concerning medical assistance regulations to recipients, physicians and other concerned parties;

Recommends that cases be investigated for criminal involvement or that corrective action be taken against recipients;

Testifies as an expert witness during official hearings;

Performs other related duties.

Knowledge of the principles, practices and theory of registered nursing;

Knowledge of medical terminology;

Knowledge of the nursing process;

Knowledge of common illnesses and the procedures generally used to treat them;

Knowledge of State and federal regulations concerning Medical Assistance;

Knowledge of prescription drugs and the usual dosages prescribed for specific illnesses;

Skill in providing and reviewing medical documentation and record-keeping;

Ability to supervise Registered Nurses and other support personnel;

Ability to recognize treatment which is excessive or inconsistent with specific diagnoses;

Ability to recognize fraudulent claims or practices;

Ability to communicate effectively with patients, professional and nonprofessional workers and the general public.

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

Experience: Two years of experience reviewing medical services claims to ensure that the nature and quality of services are in accordance with State and federal regulations.

Notes: 

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

2. 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.

1. 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.

2. 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.

Class specifications are broad descriptions covering groups of positions used by various State departments and agencies. Position descriptions maintained by the using department of agency specifically address the essential job functions of each position.

This is a Professional Service classification in the State Personnel Management System.  All positions in this classification are Professional Service positions.  Some positions in Professional Service classifications may be designated as Special Appointment in accordance with the State Personnel and Pensions Article, Section 6-405, Annotated Code of Maryland.

This classification is not assigned to a bargaining unit, as indicated by the designation of S (Supervisor), M (Manager), T (Agency Head), U (Board or Commission Member), W (Student), X (Used by Agency or Excluded by Executive Order), or Z (Confidential).  As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial and confidential employees are excluded collective bargaining.  Additionally, certain executive branch agencies are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.