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

Classification: Medicaid Health Systems Specialist RN (PN 20046588) | Contact: HumanResources@medicaid.ohio.gov

About the role

As the Utilization Management Behavioral Health Nurse in the Bureau of Clinical Operations, Ohio Department of Medicaid (ODM), your responsibilities will include:

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