Clinical Authorization Review Nurse (Medicaid Health Systems Specialist - RN)

What You Will Do At ODM:

Working Title: Clinical Authorization Review Nurse

Classification: Medicaid Health Systems Specialist RN (PN 20102136)

Office: Health Innovation & Quality

Bureau: Clinical Operations

Pay rate: $33.45/hour

Job Overview:

As the Clinical Authorization Review Nurse in the Bureau of Clinical Operations, Ohio Department of Medicaid (ODM), your responsibilities will include:

• Monitoring and evaluating contractors, projects, programs or service delivery
• Participation in prior authorization and service authorization oversight and utilization activities
• Reviewing both physical and behavioral health clinical records and files, other medical and administrative data, and patient summary/profile reports to determine if providers or care delivery meets or equals the established care standards/clinical practice guidelines set forth in Medicaid programs, professional standards, and/or evidence-based best practices, and recommending health and safety process improvements
• Reviewing and approving claims for payment
• Working collaboratively with internal and external stakeholders across a variety of departments, levels, state agencies, and MCPs to improve health services for the individuals served by ODM
• Using your nursing expertise to evaluate authorization decisions for individuals served in both Managed Care, Fee for Service and Waiver populations

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.

Position requiring assessment or reassessment of clinical appropriateness of services &/or payment policies &/or related issues in regards to Medicaid health services delivery requires current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03 & 4723.09 of Ohio revised code; additional 24 mos. exp. in nursing.

Technical Skills: Nursing

Professional Skills: Critical Thinking, Collaboration, Attention to Detail, Organizing and Planning, Verbal Communication, Written Communication, Confidentiality, Analyzation