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:
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Helping to manage an over $ 7million/ year hospital utilization contract
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Reviewing necessary medical record reviews and making a determination on hospital appeals.
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Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program.
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Participating/leading meetings with external stakeholders including law enforcement
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Developing and implementing changes to processes and procedures as needed in a team environment
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Evaluating provider clinical compliance with state and federal Program Integrity rules
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Evaluating provider medical documentation and billing practices for fraud, waste and abuse
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Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies
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Responding to provider clinical reconsideration (appeal) requests
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Consulting on clinical matters with ODM policy units and other state agencies
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Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans
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Presenting findings from clinical reviews of provider non-compliance
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Responding to inquiries from the public, consumers, providers, and other agencies
Why Work for the State of Ohio
At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees*. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes:
- 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)
- Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.
Qualifications
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
Supplemental Information
Supplemental Information:
Compensation is as listed on the posting unless required by legislation or union contract.
Must poses Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code
This positions is overtime exempt.
Travel required, as needed. Must provide own transportation. Or, in order to operate a state vehicle, you must have a valid driver's license from state of residence.
Resumes and/or attachments are not reviewed. Therefore, please provide detail in the work experience section of your application.
ADA Statement
Ohio is a Disability Inclusion State and strives to be a model employer of individuals with disabilities. The State of Ohio is committed to providing access and inclusion and reasonable accommodation in its services, activities, programs and employment opportunities in accordance with the Americans with Disabilities Act (ADA) and other applicable laws.
Drug-Free Workplace
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.
