Medical Services Reviewing Nurse II

Position Overview

This role, classified as Grade 20, is based at the MDH Office of the Inspector General for Health in Baltimore, Maryland. The primary objective is to conduct detailed analysis of Medicaid claims data to detect irregularities and identify providers who may be engaging in fraudulent or wasteful billing practices, thereby protecting the Maryland Medicaid program from abuse.

Key Duties

• Analyze Medicaid claims using data mining techniques to uncover billing anomalies and provider billing outliers.
• Conduct thorough reviews of provider billing practices with a focus on medical coding investigations, including detection of upcoding, unbundling, and inappropriate code usage inconsistent with the provider or service type.
• Plan and execute audits by selecting samples, assessing risks, developing audit strategies, and performing onsite visits to interview staff, collect documentation, and carry out audit procedures.
• Supervise and assist staff with audit plans and review their findings and reports for accuracy.
• Ensure provider compliance with COMAR regulations and applicable state and federal laws.
• Oversee vendors conducting clinical or statistical reviews and manage related contracts.
• Support certified coders in evaluating clinical aspects such as medical necessity and appropriateness of billed services.

Required Knowledge and Expertise

This position demands in-depth knowledge of nursing practice, medical coding standards (CPT, ICD-10, HCPCS), coding conventions, and general billing practices. A strong understanding of state and federal regulations and medical and surgical terminology is critical for ensuring compliance and making informed decisions.

Minimum Qualifications

• Bachelor's degree in Nursing or a related field from an accredited institution.
• At least one year of experience reviewing medical claims to confirm compliance with regulations.
• Substitutions: Two years of registered nurse experience may replace the education requirement or equivalent military service as a commissioned nursing officer on a year-for-year basis.

Desired Qualifications

• Experience identifying healthcare fraud, waste, abuse, billing irregularities, and documentation issues.
• Ability to analyze clinical records and create clear, concise reports and documentation.
• Proficiency in communicating complex clinical findings to individuals without clinical backgrounds.
• Experience in providing testimony, participating in hearings, or supporting enforcement activities.

Licenses and Certifications

• Active Registered Nurse license from the Maryland State Board of Nursing or a multi-state license with declared primary states of residence.
• Valid Maryland motor vehicle operator license for employees required to operate vehicles.

Additional Information

The selection process involves evaluation of education, training, and experience. Candidates applying with foreign credentials must provide equivalency evaluations prior to employment. Applications must be fully completed and submitted by the deadline; late or incomplete submissions will not be accepted. Resumes alone are not accepted instead of applications. The eligible list may be used for similar vacancies within state agencies for at least one year.

Application Instructions and Support

Applying online is encouraged. Paper applications, if necessary, must be submitted by the closing date to the MDH Recruitment and Selection Division in Baltimore. Supplemental documents can be faxed by the deadline. Assistance with application systems is available via phone and email.

Equal Opportunity and Accommodations

The State of Maryland is an equal opportunity employer committed to diversity and inclusion, actively encouraging applications from veterans, persons with disabilities, and bilingual candidates. Accommodations for disabilities are available upon request.

Benefits

Full State of Maryland employee benefits included.