Medical Services Reviewing Nurse I at Maryland Department of Health

University of the District of Columbia • Baltimore, MD, United States • $200k - $250k / year • 3w ago

Main Purpose of Job

The primary purpose of this position is to:

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.
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.
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.
Ensure provider billings are in compliance with COMARs and other State and Federal regulations.

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 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: None.

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.

DESIRED OR PREFERRED QUALIFICATIONS

The desired candidate should possess experience with the following:

Data mining for irregularities in medical coding by medical providers
Investigating medical coding irregularities in medical billings
Reviewing medical records and ensuring documentation supports the medical coding

The desired candidate should also possess certification as a Certified Professional Coder (CPC).

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 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.

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.

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.

All applications must be submitted online by October 1, 2024, at 11:59:00 PM.

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