Utilization Management Behavioral Health Nurse (Medicaid Health Systems Specialist - RN)

State of Ohio • Columbus, OH

4d • Onsite

About The Position

At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees. This position is within the Office of Health Innovation & Quality, Bureau of Clinical Operations/Utilization Management. The Utilization Management Behavioral Health Nurse is responsible for reviewing Clinical Coverage Policies (CCPs) to ensure service requests meet medical necessities, benefit coverage rules, and applicable Ohio Administrative Code standards. This role also involves conducting validation of service decisions, assessing behavioral health services against clinical criteria and documentation thresholds, and verifying the completeness of submissions. The nurse will assist with rules language interpretation, participate in cross-team collaboration with medical directors and policy teams, and support provider education by identifying and communicating policy gaps or common issues.

Requirements

• Current and valid license as a registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03 & 4723.09 of Ohio revised code.
• Additional 24 months experience in nursing.
• Additional 24 months experience in Behavioral Health nursing.
• Must provide own transportation. Or, in order to operate a state vehicle, you must have a valid driver's license from state of residence.

Nice To Haves

• 24 months experience as Medicaid Health Systems Analyst, (65291) may be substituted for the experience required, but not for the mandated licensure.
• Equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure.

Responsibilities

• Review Clinical Coverage Policies (CCPs) to ensure service requests meet medical necessities, benefit coverage rules, and applicable Ohio Administrative Code standards.
• Conduct validation of service decisions, including assessing whether requested behavioral health services meet required clinical criteria and documentation thresholds; verifying completeness of assessments, treatment plans, and prior authorization submissions in alignment with UM policy requirements.
• Assist with rules language by interpreting behavioral health service rules and CCP requirements; helping refine, clarify, or apply rule language during reviews and provider communications; ensuring decisions reflect correct interpretation of policy, coverage rationale, and service thresholds.
• Participate in cross-team collaboration with medical directors, reviewers, policy teams, and behavioral health leads to ensure UM consistency and alignment with statewide managed care requirements.
• Support provider education by identifying policy gaps, common documentation issues, or rule misinterpretations and communicating them through appropriate UM channels.

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 )

What This Job Offers

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