Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)

Responsibilities

• 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
• Coinciding 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

Requirements

• 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

Qualifications

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

Skills

• Technical Skills

Benefits

• Full-time
• Work Hours: 8:00 am - 5:00 pm
• Classified Indicator: Classified
• Union Exempt from Union

Pay

$40.40/hour

Schedule

Full-time