State of Ohio
Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)
State of Ohio, Columbus, Ohio, United States, 43224
Job Description - Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1) (250009LL)
Organization Medicaid
Work Location Lazarus 5 50 West Town Street Columbus 43215
Primary Location United States of America-OHIO-Franklin County-Columbus
Compensation $39.22/hour
Schedule Full-time
Primary Job Skill Nursing
Agency Overview The 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. The agency focuses on delivering a personalized care experience, improving care for children and adults with complex behavioral health needs, working collectively with partners and providers to strengthen wellness and health outcomes, streamlining administrative burdens, and ensuring financial transparency and operational accountability across all Medicaid programs and services.
Responsibilities
Helping to manage an over $7 million/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
Qualifications Current and valid license as registered nurse issued by the Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code, is required. Minimum qualifications include 12 months experience 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 database analysis). Education and experience is commensurate with the approved position description on file.
Benefits
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)
Supplemental Information Compensation is as listed on the posting unless required by legislation or union contract.
Must possess Current & valid license as registered nurse issued by Ohio Board of Nursing.
This position 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.
ADA Statement 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.
Drug‑Free Workplace The State of Ohio is a drug‑free workplace which prohibits the use of marijuana (recreational marijuana/non‑medical cannabis). 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.
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Organization Medicaid
Work Location Lazarus 5 50 West Town Street Columbus 43215
Primary Location United States of America-OHIO-Franklin County-Columbus
Compensation $39.22/hour
Schedule Full-time
Primary Job Skill Nursing
Agency Overview The 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. The agency focuses on delivering a personalized care experience, improving care for children and adults with complex behavioral health needs, working collectively with partners and providers to strengthen wellness and health outcomes, streamlining administrative burdens, and ensuring financial transparency and operational accountability across all Medicaid programs and services.
Responsibilities
Helping to manage an over $7 million/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
Qualifications Current and valid license as registered nurse issued by the Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code, is required. Minimum qualifications include 12 months experience 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 database analysis). Education and experience is commensurate with the approved position description on file.
Benefits
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)
Supplemental Information Compensation is as listed on the posting unless required by legislation or union contract.
Must possess Current & valid license as registered nurse issued by Ohio Board of Nursing.
This position 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.
ADA Statement 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.
Drug‑Free Workplace The State of Ohio is a drug‑free workplace which prohibits the use of marijuana (recreational marijuana/non‑medical cannabis). 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.
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