Rem Quality Improvement Nurse

State of Maryland•Baltimore City, MD

About The Position

The main purpose of this Medical Services Reviewing Nurse II position is to perform quality improvement activities within the Rare and Expensive Case Management (REM) program. This position works directly with the REM case management contractor to assure that the REM enrollees are receiving appropriate case management and medical services per the REM contract requirements. The review nurse communicates with the REM case management contractors, and/or the REM case managers regarding potential obstacles to care (reportable events).

Requirements

A Bachelor’s degree in Nursing or a related field from an accredited college or university.
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.
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.
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.

Nice To Haves

Previous experience in case management services and quality assurance review and reporting.
Experience with Maryland Medicaid Information System Subsystems (MMIS) and/or LTSS.
Experience with applicable state and federal laws, regulations and requirements.
Experience with Microsoft Office and Google applications.
Experience with Institutional Billing and Medicaid Waiver programs.

Responsibilities

Perform quality improvement activities within the Rare and Expensive Case Management (REM) program.
Work directly with the REM case management contractor to assure that the REM enrollees are receiving appropriate case management and medical services per the REM contract requirements.
Communicate with the REM case management contractors, and/or the REM case managers regarding potential obstacles to care (reportable events).