Ohio Department of Medicaid
Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)
Ohio Department of Medicaid, Columbus, Ohio, United States, 43224
Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)
Apply for the Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1) role at Ohio Department of Medicaid.
What You Will Do At ODM The Ohio Department of Medicaid (ODM) seeks a Registered Nurse (RN) to join our Surveillance/Utilization Review Section (SURS). SURS assists the agency in reviewing Medicaid utilization, detecting fraud, waste and abuse, and recovering inappropriate payments to providers.
Responsibilities
Help manage an over $7 million per year hospital utilization contract
Review medical record reviews and determine outcomes on hospital appeals
Supervise and train RNs, auditors, and analysts in fraud, waste and abuse identification
Participate and lead meetings with external stakeholders, including law enforcement
Develop and implement process and procedural changes in a team environment
Evaluate provider clinical compliance with state and federal Program Integrity rules
Evaluate provider documentation and billing practices for fraud, waste and abuse
Recover overpayments for medically unnecessary services via administrative procedures or referrals to health oversight agencies
Respond to provider clinical reconsideration (appeal) requests
Consult on clinical matters with ODM policy units and other state agencies
Coordinate clinical Program Integrity efforts with ODM contractors and managed care plans
Present findings from clinical reviews of provider non‑compliance
Respond to inquiries from the public, consumers, providers, and agencies
Qualifications
Completion of a graduate core program in business, management, public administration, public health, health administration, social or behavioral science, or public finance
12 months of experience in the delivery of a health services program or health services project management (e.g., health care data analysis, contract management, market & financial expertise, program communication, budget development, HMO & hospital rate development, eligibility, database analysis)
Current and valid RN license issued by the Ohio Board of Nursing
Alternatively, 12 months experience as a Medicaid Health Systems Specialist may substitute for the required experience, but not for licensure
Equivalent qualifications may substitute for experience, but not for licensure
Technical Skills Nursing
Professional Skills Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication
Agency Contact HumanResources@medicaid.ohio.gov
Unposting Date Jan 12, 2026, 11:59:00 PM
Work Location Lazarus 5
Primary Location United States of America - Ohio - Franklin County - Columbus
Compensation $39.22 per hour
Schedule Full‑time
Work Hours 8:00 am - 5:00 pm
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Government Administration
#J-18808-Ljbffr
What You Will Do At ODM The Ohio Department of Medicaid (ODM) seeks a Registered Nurse (RN) to join our Surveillance/Utilization Review Section (SURS). SURS assists the agency in reviewing Medicaid utilization, detecting fraud, waste and abuse, and recovering inappropriate payments to providers.
Responsibilities
Help manage an over $7 million per year hospital utilization contract
Review medical record reviews and determine outcomes on hospital appeals
Supervise and train RNs, auditors, and analysts in fraud, waste and abuse identification
Participate and lead meetings with external stakeholders, including law enforcement
Develop and implement process and procedural changes in a team environment
Evaluate provider clinical compliance with state and federal Program Integrity rules
Evaluate provider documentation and billing practices for fraud, waste and abuse
Recover overpayments for medically unnecessary services via administrative procedures or referrals to health oversight agencies
Respond to provider clinical reconsideration (appeal) requests
Consult on clinical matters with ODM policy units and other state agencies
Coordinate clinical Program Integrity efforts with ODM contractors and managed care plans
Present findings from clinical reviews of provider non‑compliance
Respond to inquiries from the public, consumers, providers, and agencies
Qualifications
Completion of a graduate core program in business, management, public administration, public health, health administration, social or behavioral science, or public finance
12 months of experience in the delivery of a health services program or health services project management (e.g., health care data analysis, contract management, market & financial expertise, program communication, budget development, HMO & hospital rate development, eligibility, database analysis)
Current and valid RN license issued by the Ohio Board of Nursing
Alternatively, 12 months experience as a Medicaid Health Systems Specialist may substitute for the required experience, but not for licensure
Equivalent qualifications may substitute for experience, but not for licensure
Technical Skills Nursing
Professional Skills Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication
Agency Contact HumanResources@medicaid.ohio.gov
Unposting Date Jan 12, 2026, 11:59:00 PM
Work Location Lazarus 5
Primary Location United States of America - Ohio - Franklin County - Columbus
Compensation $39.22 per hour
Schedule Full‑time
Work Hours 8:00 am - 5:00 pm
Seniority level Mid‑Senior level
Employment type Full‑time
Job function Health Care Provider
Industries Government Administration
#J-18808-Ljbffr