Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)

What You Will Do At ODM:

Office: Legal Counsel

Bureau: Program Integrity

Classification: Medicaid Health Systems Administrator 1 RN (PN: 20092018)

Job Overview:

The Ohio Department of Medicaid (ODM) is seeking a Registered Nurse (RN) to be a part of our Surveillance/Utilization Review Section (SURS). SURS is charged with helping the agency review utilization of Medicaid services, detect fraud, waste and abuse and recover inappropriate payments to providers. As a Clinical Review Nurse Supervisor your responsibilities will include:

• Helping to manage an over $ 7million/ year hospital utilization contract
• Reviewing necessary medical record reviews and making a determination on hospital appeals.
• Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program.
• Participating/leading meetings with external stakeholders including law enforcement
• Developing and implementing changes to processes and procedures as needed in a team environment
• Evaluating provider clinical compliance with state and federal Program Integrity rules
• Evaluating provider medical documentation and billing practices for fraud, waste and abuse
• Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies
• Responding to provider clinical reconsideration (appeal) requests
• Consulting on clinical matters with ODM policy units and other state agencies
• Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans
• Presenting findings from clinical reviews of provider non-compliance
• Responding to inquiries from the public, consumers, providers, and other agencies

Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a 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 base analysis); Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code;

Or 12 months experience as Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure.

Note: education & experience is to be commensurate with approved position description on file.

• Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure.

Technical Skills: Nursing

Professional Skills: Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication