Clinical Authorization Review Nurse (Medicaid Health Systems Specialist – RN) | Ohio Department of Medicaid

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THIS POSITION MAY BE TELEWORK ELIGIBLE ON A HYBRID BASIS.


About Us


The Ohio Department of Medicaid (ODM) is committed to improving the health of Ohioans and strengthening communities and families through quality care. ODM is implementing the next generation of Ohio Medicaid to fulfill its bold, new vision for Ohio’s Medicaid program – focusing on the individual rather than the business of managed care.


The goals of the next generation of Ohio Medicaid are:


  • Emphasize a personalized care experience
  • Improve care for children and adults with complex behavioral health needs
  • Improve wellness and health outcomes
  • Support providers in better patient care
  • Increase program transparency and accountability


What You Will Do At ODM


Working Title: Clinical Authorization Review Nurse


Classification: Medicaid Health Systems Specialist RN (PN 20046588, 20037628)


Office: Health Innovation & Quality


Bureau: Clinical Operations


Pay rate: $30.93/per hour


Job Overview


As the Clinical Authorization Review Nurse in the Bureau of Clinical Operations, Ohio Department of Medicaid (ODM), your responsibilities will include:


  • Monitoring and evaluating contractors, projects, programs or service delivery
  • Participation in prior authorization and service authorization oversight and utilization activities
  • Reviewing both physical and behavioral health clinical records and files, other medical and administrative data, and patient summary/profile reports to determine if providers or care delivery meets or equals the established care standards/clinical practice guidelines set forth in Medicaid programs, professional standards, and/or evidence-based best practices, and recommending health and safety process improvements
  • Reviewing and approving claims for payment
  • Working collaboratively with internal and external stakeholders across a variety of departments, levels, state agencies, and MCPs to improve health services for the individuals served by ODM
  • Using your nursing expertise to evaluate authorization decisions for individuals served in both Managed Care, Fee for Service and Waiver populations


Must possess a current & valid license as registered nurse (RN) as issued by Ohio Board of Nursing, pursuant to Sections 4723.03 & 4723.09 of Ohio revised code.


Current & valid license to practice professional Nursing as a Registered Nurse (i. e., RN) in Ohio as issued by the Board of Nursing pursuant to Sections 4723.03 to 4723.09, inclusive of Ohio Revised Code; additional 24 months of experience in Nursing.


Training & Development Required to Remain in Classification After Employment: Biennial renewal of license in practice as Registered Nurse per Section 4723.24 of Ohio Revised Code.


Primary Location


United States of America-OHIO-Franklin County-Columbus


Work Locations


Lazarus 5


Organization


Ohio Department of Medicaid


Classified Indicator


Classified


Bargaining Unit / Exempt


Bargaining Unit


Schedule


Full-time


Work Hours


8:00 a.m. – 5:00 p.m.


Compensation


$30.93/per hour


Unposting Date


Feb 5, 2023, 10:59:00 PM


Job Function


Nursing


Agency Contact Name


ODM Human Resources


Agency Contact Information


HumanResources@medicaid.ohio.gov