Clinical Quality Oversight Nurse (Medicaid Health Systems Specialist - RN)
About The Position
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
Requirements
- 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.
- Position requiring assessment or reassessment of clinical appropriateness of services &/or payment policies &/or related issues in regards to Medicaid health services delivery requires current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03 & 4723.09 of Ohio revised code; additional 24 mos. exp. in nursing.
- Or for positions other than those requiring valid license as registered nurse, 24 months experience as Medicaid Health Systems Analyst, (65291) may be substituted for the experience required, but not for the mandated licensure.
- Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure.
- Must provide own transportation. Or, in order to operate a state vehicle, you must have a valid driver's license from state of residence.
Responsibilities
- 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
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 )
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
