Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)

About Us:

Investing in opportunities for Ohioans that work for every person and every family in every corner of our state is at the hallmark of Governor DeWine’s agenda for Ohio’s future. To ensure Ohio is “the best place to live, work, raise and family and start a business,” we must have strong schools, a great quality of life, and compassion for those who need our help.

Ohio Department of Medicaid plays a unique and necessary role in supporting the governor’s vision. As the single state Medicaid agency responsible for administering high-quality, person-centric healthcare, the department is committed to supporting the health and wellbeing of nearly one in every four Ohioans served. We do so by:

                •    Delivering a personalized care experience to more than three million people served.
                •    Improving care for children and adults with complex behavioral health needs.
                •    Working collectively with our partners and providers to measurably strengthen wellness and health outcomes.
                •    Streamlining administrative burdens so doctors and healthcare providers have more time for patient care.
                •    Ensuring financial transparency and operational accountability across all Medicaid programs and services.

• What You Will Do At ODM:

Office: Legal Counsel

Bureau: Program Integrity

• Classification: Medicaid Health Systems Administrator 1 RN (PN: 20092018)

Job Overview:

The Ohio Department of Medicaid (ODM) is seeking a Registered Nurse (RN) to be a part of our Surveillance/Utilization Review Section (SURS). SURS is charged with helping the agency review utilization of Medicaid services, detect fraud, waste and abuse and recover inappropriate payments to providers. As a Clinical Review Nurse Supervisor your responsibilities will include:

• Helping to manage an over $ 7million/ year hospital utilization contract
• Reviewing necessary medical record reviews and making a determination on hospital appeals.
• Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program.
• Participating/leading meetings with external stakeholders including law enforcement
• Developing and implementing changes to processes and procedures as needed in a team environment
• Evaluating provider clinical compliance with state and federal Program Integrity rules
• Evaluating provider medical documentation and billing practices for fraud, waste and abuse
• Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies
• Responding to provider clinical reconsideration (appeal) requests
• Consulting on clinical matters with ODM policy units and other state agencies
• Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans
• Presenting findings from clinical reviews of provider non-compliance
• Responding to inquiries from the public, consumers, providers, and other agencies

At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes:

• Medical Coverage
• Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period
• Paid time off, including vacation, personal, sick leave and 11 paid holidays per year
• Childbirth, Adoption, and Foster Care leave
• Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)
• Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation)

*Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.

Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data base analysis); Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code;

Or 12 months experience as Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure.

Note: education & experience is to be commensurate with approved position description on file.

-Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure.
 

Technical Skills: Nursing

• Professional Skills: Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication
• Compensation is as listed on the posting unless required by legislation or union contract.

Supplemental Information:

Must poses Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code

This positions is overtime exempt.

Travel required, as needed. Must provide own transportation. Or, in order to operate a state vehicle, you must have a valid driver's license from state of residence.

Resumes and/or attachments are not reviewed. Therefore, please provide detail in the work experience section of your application.

Ohio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws.

The State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting.