Office : Health Innovation & Quality

Bureau : Clinical Operations/Utilization Management

Classification :

Job Overview :

As the Utilization Management Section Chief - RN in the Office of Health Innovation & Quality, Ohio Department of Medicaid (ODM), your responsibilities will include:
• Working under the Bureau Chief of Clinical Operations and the clinical direction of ODM's Medical Directors.
• Provide oversight to the processes of identifying, managing, and tracking UM clinical operations, technology, quality, and regulatory oversight to advance the objectives of ODM.
• Manage two teams of nurses and oversee UM of vendor and managed care entities.
• Develop reports to support and monitor goals of overall UM, across ODM programs.
• Oversee day to day operational activities of the Utilization Management Program across ODM programs
• Develop and maintaining written policies and procedures regarding authorization processes and monitoring of utilization management.
• Ensure the consistent application of review criteria across ODM programs.
• Ensure decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating members.
• Ensure notices of adverse action are provided and meet requirements across ODM programs.
• Ensure authorization decisions are made within allowable timeframes.
• Evaluate under and over utilization information for impact on member care, health outcomes, and access to care.
• Assist with the development and implementation of comprehensive onboarding and ongoing training

Qualifications

Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 24 mos. exp. in planning & administering 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 analysis); Current and valid license to practice professional nursing as a Registered Nurse (RN) in the State of Ohio, issued by the Ohio Board of Nursing pursuant to Sections 4723.01 through 4723.40 of the Ohio Revised Code.

-Or for positions requiring valid license as registered nurse, 24 months experience as a Medicaid Health Systems Administrator 1, (65295) may be substituted for the experience required, but not for the mandated licensure.

-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; Health Administration

Professional Skills: Critical Thinking, Collaboration, Goal setting, Interpreting Data, Leading Others, Managing Meetings, Organizing and Planning, Decision Making, Motivating Others, Verbal Communication, Written Communication