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

Contact: HumanResources@medicaid.ohio.gov. Work Location: 50 West Town Street, Columbus, Ohio 43215. Classification: Medicaid Health Systems Administrator 1. Classified, Exempt from union.

About the role

Investing in opportunities for Ohioans that work for every person and every family in every corner of our state is at the hallmark of Governor DeWine's agenda for Ohio's future. To ensure Ohio is "the best place to live, work, raise a family and start a business," we must have strong schools, a great quality of life, and compassion for those who need our help.

The Ohio Department of Medicaid plays a unique and necessary role in supporting the governor's vision. As the single state Medicaid agency responsible for administering high-quality, person-centric healthcare, the department is committed to supporting the health and wellbeing of nearly one in every four Ohioans served. We do so by delivering a personalized care experience to more than three million people served; improving care for children and adults with complex behavioral health needs; working collectively with our partners and providers to measurably strengthen wellness and health outcomes; streamlining administrative burdens so doctors and healthcare providers have more time for patient care; and ensuring financial transparency and operational accountability across all Medicaid programs and services.

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.

Responsibilities

• Helping to manage an over $7 million/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

Qualifications

• Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance
• 12 months experience 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 and valid license as registered nurse as