Clinical Review Nurse Supervisor - PN 20092018 (Medicaid Health Systems Administrator 1) - copy

State of Ohio • Columbus, OH

6d • Onsite

About The Position

The Ohio Department of Medicaid is seeking a Registered Nurse to join its Surveillance/Utilization Review Section (SURS), within the Office of Legal Counsel’s Bureau of Program Integrity. SURS reviews Medicaid service utilization, detects fraud, waste, and abuse, and recovers inappropriate provider payments. The position supervises and trains RNs, Auditors, and Analysts and helps manage a hospital utilization contract valued at over $7 million per year. The role is based at 50 West Town Street in Columbus, Ohio, and requires reporting to that location full-time. Travel may be required as needed; the employee must provide their own transportation or hold a valid driver’s license from their state of residence to operate a state vehicle.

Requirements

• Current and valid Ohio Registered Nurse license issued by the Ohio Board of Nursing under Sections 4723.03–4723.09 of the Ohio Revised Code.
• Completion of a graduate core program in business, management or public administration, public health, health administration, social or behavioral science, or public finance.
• 12 months of experience delivering a health services program or managing a health services project.
• Experience as a Medicaid Health Systems Specialist (65293) may substitute for the required experience, but not for required licensure.
• Equivalent of the stated minimum class qualifications may substitute for the required experience, but not for required licensure.
• Must report full-time to the Columbus work location.
• Must provide own transportation for required travel or have a valid driver's license from their state of residence to operate a state vehicle.

Responsibilities

• Help manage a hospital utilization contract valued at over $7 million per year.
• Review medical records and make determinations on hospital appeals.
• Supervise and train RNs, Auditors, and Analysts in identifying Medicaid fraud, waste, and abuse.
• Participate in and lead meetings with external stakeholders, including law enforcement.
• Develop and implement process and procedure changes in a team environment.
• Evaluate provider clinical compliance with state and federal Program Integrity rules.
• Evaluate provider medical documentation and billing practices for fraud, waste, and abuse.
• Recover overpayments for medically unnecessary services through administrative procedures and/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 other agencies.

Benefits

• Medical coverage.
• Free dental, vision, and basic life insurance premiums after the eligibility period.
• Paid time off, including vacation, personal, and sick leave, and 11 paid holidays per year.
• Childbirth, adoption, and foster care leave.
• Education and development opportunities, including Employee Development Funds and Public Service Loan Forgiveness.
• Public retirement systems, including OPERS, STRS, SERS, and HPRS, and optional Ohio Deferred Compensation.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager