State of Maryland

A Medical Services Reviewing Nurse I is the intermediate 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.  The employee also conducts interviews to guard against fraud and abuse.  Employees in this classification do not supervise other positions.

Employees in this classification receive moderate supervision from a Medical Assistance Reviewing Nurse Supervisor or other higher-level 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 I and the Medical Services Reviewing Nurse II are differentiated on the basis of degree of supervisory control exercised by the supervisor over these employees.  The Medical Services Reviewing Nurse I performs duties under close supervision at times and under general supervision at other times depending on the complexity of the specific duty being performed, while the Medical Services Reviewing Nurse II performs the full range of duties and responsibilities under general supervision.

Reviews claims for medical assistance from physicians and other health care providers to ensure that the claim is consistent with State and federal regulations and that the 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 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 recognize treatment which is excessive or inconsistent with diagnoses;

Ability to recognize fraudulent claims or practices;

Ability to communicate effectively with patients, professionals and other workers and the general public.

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.

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 or 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 assigned to Bargaining Unit E, Health Care Professionals classes. As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial, and confidential employees are excluded from collective bargaining. Additionally, certain executive branch agencies are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.

This classification is one level in a Non-Competitive Promotion (NCP) series.  NCP promotions are promotions by which employees may advance in grade and class level from trainee to full performance levels in a classification series.  In order to be non-competitively promoted to the next level in a NCP series an employee must: 1) perform the main purpose of the class as defined in the Nature of Work section of the class specification; 2) receive the type of supervision defined in the class specification, and 3) meet the minimum qualifications of the classification.