Utilization Management Section Chief - RN (Medicaid Health Systems Administrator 2 - RN)

State of Ohio • Columbus, OH

4d • Onsite

About The Position

The State of Ohio is a drug-free workplace which prohibits the use of marijuana (recreational marijuana/non-medical cannabis). Please note, this position may be subject to additional restrictions pursuant to the State of Ohio Drug-Free Workplace Policy (HR-39), and as outlined in the posting. As the Utilization Management Section Chief - RN in the Office of Health Innovation & Quality, Ohio Department of Medicaid (ODM), your responsibilities will include working under the Bureau Chief of Clinical Operations and the clinical direction of ODM's Medical Directors. You will provide oversight to the processes of identifying, managing, and tracking UM clinical operations, technology, quality, and regulatory oversight to advance the objectives of ODM. You will manage two teams of nurses and oversee UM of vendor and managed care entities. You will develop reports to support and monitor goals of overall UM, across ODM programs. You will oversee day to day operational activities of the Utilization Management Program across ODM programs. You will develop and maintain written policies and procedures regarding authorization processes and monitoring of utilization management. You will ensure the consistent application of review criteria across ODM programs. You will ensure decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating members. You will ensure notices of adverse action are provided and meet requirements across ODM programs. You will ensure authorization decisions are made within allowable timeframes. You will evaluate under and over utilization information for impact on member care, health outcomes, and access to care. You will assist with the development and implementation of comprehensive onboarding and ongoing training.

Requirements

• Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 24 mos. exp. in planning & administering health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data analysis); Current and valid license to practice professional nursing as a Registered Nurse (RN) in the State of Ohio, issued by the Ohio Board of Nursing pursuant to Sections 4723.01 through 4723.40 of the Ohio Revised Code.
• For positions requiring valid license as registered nurse, 24 months experience as a Medicaid Health Systems Administrator 1, (65295) 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.
• Nursing
• Health Administration
• Critical Thinking
• Collaboration
• Goal setting
• Interpreting Data
• Leading Others
• Managing Meetings
• Organizing and Planning
• Decision Making
• Motivating Others
• Verbal Communication
• Written Communication

Responsibilities

• Provide oversight to the processes of identifying, managing, and tracking UM clinical operations, technology, quality, and regulatory oversight to advance the objectives of ODM.
• Manage two teams of nurses and oversee UM of vendor and managed care entities.
• Develop reports to support and monitor goals of overall UM, across ODM programs.
• Oversee day to day operational activities of the Utilization Management Program across ODM programs.
• Develop and maintaining written policies and procedures regarding authorization processes and monitoring of utilization management.
• Ensure the consistent application of review criteria across ODM programs.
• Ensure decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating members.
• Ensure notices of adverse action are provided and meet requirements across ODM programs.
• Ensure authorization decisions are made within allowable timeframes.
• Evaluate under and over utilization information for impact on member care, health outcomes, and access to care.
• Assist with the development and implementation of comprehensive onboarding and ongoing training.

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