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MEDICAL SERVICES REVIEWING NURSE II

Recruitment #15-004251-0003

GRADE

17

LOCATION OF POSITION

DHMH, Fraud Detection and Determination Unit (FDDU), Baltimore, MD

Main Purpose of Job

The primary purpose of this position is to identify and reduce fraud, waste, and abuse against the Maryland Medicaid Program. The incumbent will consult with and advise data specialists in creating data runs to identify billing anomalies and monitor services paid by the Program. Utilizing specialized nursing knowledge and extensive experience in Current Procedural Terminology coding (CPT), Internal Classification of Disease coding (ICD-9), and Healthcare Common Procedure Coding (HCPCS) and general billing experience, the incumbent will analyze data runs, review claims data, request and review medical records, and assist in conducting both on-site and desk reviews of medical records and documentation.

MINIMUM QUALIFICATIONS

Education: Possession of 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.

Note: 

1. Two years of experience as a Registered Nurse may be substituted 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.

DESIRED OR PREFERRED QUALIFICATIONS

. Experience reviewing Medical claims & Medical records.

. Assist in conducting both onsite and desk reviews of medical records.

. Experience investigating health care fraud and or identifying aberrant billing errors.

. Experience in Excel.

LICENSES, REGISTRATIONS AND CERTIFICATIONS

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. A copy of your current license or license verification must accompany your application.

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.

SELECTION PROCESS

Applicants who meet the minimum qualifications will be evaluated.  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.  For education obtained outside the U.S., a copy of the equivalent American education as determined by a foreign credential evaluation service must accompany the application.  All information concerning your qualifications must be submitted by the closing date.  We will not consider information submitted after this date.  Applicants certified to list will receive eligibility for a period of one (1) year.
Eligibility may be extended beyond one (1) year period.  For Recorded Job Information Call:  410-767-6018.

Online applications are highly recommended, however the paper application may be submitted to DHMH, Recruitment and Selection Division, 201 W. Preston St., Room 114-B, Baltimore, MD 21201.  The paper application must be received by 5 pm, close of business, on the closing date for the recruitment, no postmarks will be accepted.

Incorrect application forms will not be accepted.

If you need to submit additional information, the preferred method is to upload.  If unable to upload, please fax requested information only to 410-333-5689.

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

BARGAINING UNIT STATUS

The incumbent in this position is a member of a covered bargaining unit and will be required to pay a bi-weekly service fee to the exclusive representative of the bargaining unit.

BENEFITS

FURTHER INSTRUCTIONS

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

The resulting certified eligible list for this recruitment may be used for similar positions in this or other State agencies.

We thank our Veterans for their service to our country, and encourage them to apply.




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