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MEDICAL SERVICES REVIEWING NURSE II

Recruitment #15-004251-0005

GRADE

17

LOCATION OF POSITION

DHMH, Office of Health Services, Baltimore, MD

Main Purpose of Job

This Medical Review Nurse II position investigates disputes between enrollees and MCOs involving complex complaints and issues of covered as well as denied benefits, services or access. The review nurse directs the Managed Care Organization (MCO) staff to provide the medical information necessary for resolution of the issue. The nurse is required to perform medical record reviews and works with the member's provider and MCO on the issues to assure the member is linked to the appropriate medical services including case management, care coordination and/or other medically necessary services. The review nurse also renders technical assistance to local health departments as part of the complaint resolution process. The review nurse provides the client with educating regarding the MCO Program's navigation and utilization and assists the client to understand and utilize the Enrollee Appeal process for denied/reduced and/or terminated healthcare benefits or services. All calls to the Enrollee Action Line from pregnant women are referred to and assessed by the review nurse to determine the acuity level of the issue and assistance required. The pregnant women are linked to OB services in as timely a manner as possible and provided education regarding the prenatal and postpartum services available for access as well as assisted to plan for pediatric services prior to delivery. Referrals are made to Local Health Departments for link to other pertinent available local resources such as WIC, child safety seats, infant clothing and supplies.

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.

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 license or license number must accompany 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.

Should additional information regarding this recruitment be required, please contact the DHMH Recruitment and Selection Division at 410-767-1251 or via email at dhmh.jobs@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.

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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