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

State of Ohio • Columbus, OH

4d • Onsite

About The Position

The Ohio Department of Medicaid is seeking a Registered Nurse to join its Surveillance/Utilization Review Section (SURS), which reviews utilization of Medicaid services, detects fraud, waste, and abuse, and recovers inappropriate provider payments. The Clinical Review Nurse Supervisor oversees clinical review activities and staff, including review of hospital utilization and appeals, evaluation of provider compliance and documentation, and efforts to recover overpayments. The role also coordinates with contractors, managed care plans, policy units, other agencies, providers, and law enforcement.

This is a permanent, full-time classified position in the Office of Legal Counsel, Program Integrity Bureau, located at 50 West Town Street, Columbus, Ohio. The standard work hours are 8:00 a.m. to 5:00 p.m.; the employee must report to the work location full-time. Travel is required as needed, and 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 Registered Nurse license issued by the Ohio Board of Nursing pursuant to Ohio Revised Code Sections 4723.03–4723.09.
• Completion of a graduate core program in business, management or public administration, public health, health administration, social or behavioral science, or public finance.
• Twelve months of experience delivering a health services program or managing a health services project, with examples including health care data analysis, health services contract management, health care market and financial expertise, health services program communication, health services budget development, HMO and hospital rate development, health services eligibility, or health services database analysis.
• Alternatively, 12 months of experience as a Medicaid Health Systems Specialist (65293) may substitute for the required experience, but not for mandated licensure.
• The equivalent of the minimum class qualifications may substitute for the required experience, but not for mandated licensure.
• Must report full-time to the Columbus work location.
• Must provide own transportation or have a valid driver’s license from their state of residence to operate a state vehicle.
• No employment-based visa sponsorship is provided.

Responsibilities

• Help manage a hospital utilization contract valued at more than $7 million per year.
• Review medical records and make determinations on hospital appeals.
• Supervise and train registered nurses, auditors, and analysts in identifying Medicaid fraud, waste, and abuse.
• Participate in or 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 completion of the eligibility period.
• Paid vacation, personal leave, 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.
• Optional deferred compensation through Ohio Deferred Compensation.

What This Job Offers

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