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SalaryHYBRID - Utilization Review Registered Nurse (Medicaid Health Systems Specialist - RN)
(2400013X)THIS POSITION MAY BE TELEWORK ELIGIBLE ON A HYBRID BASIS.
About Us:
The Ohio Department of Medicaid (ODM) is committed to improving the health of Ohioans and strengthening communities and families through quality care. ODM is implementing the next generation of Ohio Medicaid to fulfill its bold, new vision for Ohio’s Medicaid program - focusing on the individual rather than the business of managed care.
The goals of the next generation of Ohio Medicaid are:
- Emphasize a personalized care experience
- Improve care for children and adults with complex behavioral health needs
- Improve wellness and health outcomes
- Support providers in better patient care
- Increase program transparency and accountability
What You Will Do At ODM:
Office: Legal Counsel
Bureau: Program Integrity
Classification:Medicaid Health Systems Specialist - RN (PN 20043105)
Pay rate: $31.86/per hour
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 Utilization Review RN, your responsibilities will include:
- Reviewing clinical utilization of Medicaid services
- 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
- Supporting hospital Utilization Review contract management
- Presenting findings from clinical reviews of provider non-compliance
- Responding to inquiries from the public, consumers, providers and other agencies
Must possess a current & valid license as Registered Nurse (RN) as issued by Ohio Board of Nursing, pursuant to Sections 4723.03 & 4723.09 of Ohio revised code.
The preferred candidate will take direction and work toward established goals, with high attention to detail and strong communication skills.
What’s In It For You:
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
- Quality, affordable, and competitive medical benefits are offered through the available Ohio Med plans.
Dental, Vision and Basic Life Insurance
- Dental, vision, and basic life insurance premiums are free after completed eligibility period. Length of eligibility period is dependent on union representation.
Time Away From Work and Work/Life Balance
- Paid time off, including vacation, personal, and sick leave
- 11 paid holidays per year
- Childbirth/Adoption leave
Employee Development Funds
- The State of Ohio offers a variety of educational and professional development funding that varies based on whether you are a union-exempt employee or a union-represented employee.
Ohio Public Employees Retirement System
- OPERS is the retirement system for State of Ohio employees. The employee contributes 10% of their salary towards their retirement. The employer contributes an amount equal to 14% of the employee’s salary. Visit the OPERS website for more information.
Deferred Compensation
- The Ohio Deferred Compensation program is a 457(b) voluntary retirement savings plan. Visit the Ohio Deferred Compensation website for more information.
Current & valid license to practice professional Nursing as a Registered Nurse (i. e., RN) in Ohio as issued by the Board of Nursing pursuant to Sections 4723.03 to 4723.09, inclusive of Ohio Revised Code; additional 24 months of experience in Nursing.
Training & Development Required to Remain in Classification After Employment: Biennial renewal of license in practice as Registered Nurse per Section 4723.24 of Ohio Revised Code.
Technical Skills: Nursing
Professional Skills: Critical Thinking, Collaboration, Interpreting Data, Verbal Communication, Written Communication, Confidentiality, Analyzation
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.
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.
Supplemental Information:
Compensation is as listed on the posting unless required by legislation or union contract.
Travel required, some with overnight stays. 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.
The final candidate selected for this position will be required to undergo a criminal background check. Criminal convictions do not necessarily preclude an applicant from consideration for a position. An individual assessment of an applicant's prior criminal convictions will be made before excluding an applicant from consideration.
