RN Manager/Supervisor Utilization Review Full-time
State of Ohio

Clinical Review Nurse Supervisor - PN 20092018 (Medicaid Health Systems Administrator 1)

State of Ohio Uptown District, OH 43215, US
$40.40 / hour

All job postings will expire at 11:59 PM Eastern Time on the application deadline.

Organization: Medicaid

Agency Contact Name and Information: HumanResources@medicaid.ohio.gov

Work Location:

50 West Town Street

Columbus, Ohio, 43215

United States

Compensation: $40.40

Schedule: Permanent - Full Time

Work Hours: 8:00AM - 5:00PM

Classified Indicator: Classified

Union: Exempt from union

Primary Job Skill: Nursing

Who We Are

Investing in opportunities for Ohioans that work for every person and every family in every corner of our state is at the hallmark of Governor DeWine’s agenda for Ohio’s future. To ensure Ohio is “the best place to live, work, raise and family and start a business,” we must have strong schools, a great quality of life, and compassion for those who need our help.

Responsibilities

Ohio Department of Medicaid plays a unique and necessary role in supporting the governor’s vision. As the single state Medicaid agency responsible for administering high-quality, person-centric healthcare, the department is committed to supporting the health and wellbeing of nearly one in every four Ohioans served. We do so by:

  • Delivering a personalized care experience to more than three million people served.
  • Improving care for children and adults with complex behavioral health needs.
  • Working collectively with our partners and providers to measurably strengthen wellness and health outcomes.
  • Streamlining administrative burdens so doctors and healthcare providers have more time for patient care.
  • Ensuring financial transparency and operational accountability across all Medicaid programs and services.

What You'll Do

Office: Legal Counsel

Bureau: Program integrity

Classification: Medicaid Health Systems Administrator 1 (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:

  • Helping to manage an over $ 7million/ year hospital utilization contract
  • Reviewing necessary medical record reviews and making a determination on hospital appeals.
  • Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program.
  • Participating/leading meetings with external stakeholders including law enforcement
  • Developing and implementing changes to processes and procedures as needed in a team environment
  • 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
  • Presenting findings from clinical reviews of provider non-compliance
  • Responding to inquiries from the public, consumers, providers, and other agencies

Additional Information

The Ohio Department of Medicaid does not provide employment-based visa sponsorship.

Compensation is as listed on the posting unless required by legislation or union contract.

The work location of this position is 50 West Town Street, Columbus, Ohio 43215. You will be required to report to this work location full-time, if selected.

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.

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 has Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure, if required.

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.

Job Skills: Nursing, Health Administration

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.

Share this job

Share to FB Share to LinkedIn Share to Twitter

Related Jobs

RN Manager/Supervisor Full-time
Ohio Living

RN Unit Manager

Ohio Living Delaware, OH
It's fun to work in a company where people truly BELIEVE in what they're doing! Our intention is to have employees who are passionate about making their personal mission statement come to life each day at work! Be it through providing healing, eradicating loneliness, contributing to efficiencies, streamlining processes, being dependable, sparking creativity or something else, the demonstration of HOW you do your job is just as important as WHAT you do in your job. Alongside our valued employees, we are making a difference throughout the state of Ohio in the lives of those that need healthcare or those embracing the next chapter of their lives. Sustained members of our team demonstrate accountable behavior and share our values of customer service, innovation, integrity, inclusion, financial stewardship, leadership and care. The Unit Manager - RN supervises the day-to-day activities of a designated unit or area of the Nursing Department in accordance with current federal, state and local standards, guidelines, and regulations to ensure that the highest degree of quality care is maintained at all times. Essential Activities and Tasks Operations Management - 20% Ensures that all staff involved in providing care to residents and patients are aware of the care plan/documentation and that care plans are used in administering daily care to residents and patients. Monitors all nursing services and care to ensure that all resident and patient care needs are met. Monitors medication passes and treatment schedules to ensure that medications and treatment are administered as ordered. Oversees the use of restraints when necessary and in accordance with the facility's policies and procedures. Ensures that a stock level of medications, medical supplies, equipment, etc., is maintained at all times to meet the needs of the residents. Monitors ancillary items, overtime, staffing and all other assigned budget item lines to stay within the current budget. Participates in reviewing potential admissions to ensure that care needs can be met. Consistently shares opinions and observations of departmental operations with the Director of Nursing. Willingly and consistently shares observations and insights of departmental operations that may improve quality and efficiencies of department. Attends all-employee and departmental meetings and in-service training as scheduled or as directed. People Management and Development - 20% Supervises a designated unit or area of the Nursing Department at a life plan community. Fosters a positive work environment that attracts, retains, and motivates employees working with the DON and ADON to help reduce turnover. Interviews, selects, and orients new direct reports. Defines, establishes, and promotes performance expectations so direct reports understand and demonstrate excellence through high quality and consistent performance. Evaluates job performance of direct reports in accordance with the company policy and procedure and provides developmental guidance to staff for improved performance and growth. Monitors accountability with organization requirements prescribed by the Employee Handbook. Documents and engages employees who are routinely not observing these requirements in an effort to achieve compliance. Works with Human Resources when circumstances arise that necessitate further documentation and intervention. Participates in the development, planning, scheduling, conducting, and monitoring of in-service training programs, on-the-job training, and orientation programs for departmental staff. Ensures that there is a reasonable and sufficient plan for staffing should a direct report be absent or a direct reporting position be vacant. Responds timely and thoughtfully to questions, requests, and work product from departmental staff that has been provided for review and approval. Care Management and Service Delivery - 20% Coordinates resident/patient care with other departments, including Culinary, Housekeeping, Laundry, Maintenance, Therapy, Activities, and Social Services to ensure the continuity of care. Attends and participates in care conference meetings. Resident, Patient and Family Relations - 20% Interacts with residents and patients to ensure that quality care and positive resident/patient and staff relations are taking place. Maintains open and trust-building relationships with residents, patients, and family members, responding professionally and promptly to any requests or concerns. Quality, Compliance, and Risk Management - 10% Assists with developing, maintaining, and updating the policies and procedures that govern the day-to-day functions of the Nursing Department in compliance with federal, state, and local regulations (i.e. HIPAA, etc.). Participates in daily quality improvement care issues (i.e. therapy, falls, infection control, wound care, hospital readmissions, etc.). Assists in identifying, evaluating, and classifying routine and job-related functions to ensure that nursing services tasks involving potential exposure to blood/body fluids are properly identified and recorded. Ensures that resident rooms, treatment areas, work areas/equipment are maintained in a clean, sanitary, and safe manner. Ensures, that medications are secured on premises at all times. Develops and implements quality assurance assessments to identify deficiencies. Develops and recommends plans to correct the identified deficiencies. Ensures that monthly pharmacy QA results are addressed. Works with the DON to help reduce hospital readmissions. Maintains the confidentiality of resident information and honors the residents’ personal and property rights. Administrative, Reporting, and Reimbursement Management - 10% Ensures completion of necessary medical forms and reporting by nursing staff on the unit. Produces reports, evaluations, studies, etc., as necessary. Ensures that all documentation is informative and descriptive of services/care provided. Collaborates with MDS and direct care staff to optimize case mix and RUG scores, which may include checking documentation for accuracy and educating staff. All other duties as assigned. Qualifications Education Nursing degree from an accredited college, university or vocational school required. Current unencumbered license for the state of Ohio to practice as a Registered Nurse (RN) required. Experience One year experience as a supervisor in a hospital, long term care facility, or other related health care facility required. Three years experience working as a nurse in a hospital, long term care facility, or other related health care facility required. Proficiency with Windows, Microsoft Office (Word, Excel, PowerPoint), and the internet required. Proficiency with electronic medical records (EMR) preferred. Other Requirements Must be able to read, write, speak, and understand the English language. Working Conditions and Special Requirements Sitting - Up to 4 hours/day Standing - Up to 8 hours/day Walking - Up to 6 hours/day Lifting, transferring, pushing or pulling residents/patients or equipment/supplies - Up to 50 pounds On-call availability - scheduled rotation Subject to falls, burns from equipment, odors, and cuts - Workday Subject to residents/patients with various disease processes - Occasional May be exposed to infectious waste, disease, conditions, etc. including exposure to the AIDS and Hepatitis B viruses - Work day Risk Category for Exposure to Bloodborne Diseases - I
RN Manager/Supervisor Other
Ohio Living

RN Charge Nurse

Ohio Living Delaware, OH
It's fun to work in a company where people truly BELIEVE in what they're doing! Our intention is to have employees who are passionate about making their personal mission statement come to life each day at work! Be it through providing healing, eradicating loneliness, contributing to efficiencies, streamlining processes, being dependable, sparking creativity or something else, the demonstration of HOW you do your job is just as important as WHAT you do in your job. Alongside our valued employees, we are making a difference throughout the state of Ohio in the lives of those that need healthcare or those embracing the next chapter of their lives. Sustained members of our team demonstrate accountable behavior and share our values of customer service, innovation, integrity, inclusion, financial stewardship, leadership and care. The Charge Nurse - RN supervises the day-to-day nursing activities of the Certified Nursing Assistant (CNA) in accordance with company standards and federal, state, and local standards, guidelines, and regulations to ensure that the highest degree of quality care is maintained at all times. Essential Activities and Tasks Operations Management and Administration - 70% Directs the day-to-day functions of the nursing activities in accordance with current rules, regulations, and guidelines that govern the facility, including the making of work assignments to Nursing Assistants. Assists in implementing methods for coordinating nursing services to ensure continuity of residents care. Administers medications and treatments in accordance with physician orders and nursing standards of practice. Represents the nursing department during Interdisciplinary Care Plan meetings. Is able to answer questions related to the plan of care and delivery of services. Participates in various committee meetings. Makes work assignments and meets with Nursing Assistants regularly to assist in identifying and correcting problem areas, and the improvement of care and services. Provides direct nursing care as needed. Consults with the residents’ physicians in planning resident care, treatment, rehabilitation, etc. as needed. Notifies residents’ physicians and families when there is a change in the resident’s condition. Authorizes and monitors the use of restraints when necessary and in accordance with the facility policies and procedures. Admits, transfers and discharges patients as necessary. Works with Unit Manager to help reduce hospital readmissions. Attends all-employee and departmental meetings and in-service training as scheduled or as directed. Quality and Compliance, and Risk Management - 20% Ensures that nursing procedures are followed by nursing service personnel, and that they reflect the day-to-day nursing care procedures used by the facility. Participates in the maintenance, and implementation of the facility’s quality assurance program. Ensures the procedures for the administration, storage and control of medications and supplies are being followed by nursing staff. Ensures that resident rooms, treatment areas, work areas and equipment are maintained in a clean, sanitary, and safe manner. People Management and Development - 10% Supervises CNAs. Fosters a positive work environment that attracts, retains, and motivates employees. Interviews, selects, and orients new direct reports. Defines, establishes, and promotes performance expectations so direct reports understand and demonstrate excellence through high quality and consistent performance. Evaluates job performance of direct reports in accordance with the company policy and procedure and provides developmental guidance to staff for improved performance and growth. Monitors accountability with organization requirements prescribed by the Employee Handbook. Documents and engages employees who are routinely not observing these requirements in an effort to achieve compliance. Works with Human Resources when circumstances arise that necessitate further documentation and intervention. Participates in the development, planning, scheduling, conducting, and monitoring of in-service training programs, on-the-job training, and orientation programs for departmental staff. Ensures that there is a reasonable and sufficient plan for staffing should a direct report be absent or a direct reporting position be vacant. Responds timely and thoughtfully to questions, requests, and work product from departmental staff that has been provided for review and approval. All other duties as assigned. Qualifications Education Nursing degree from an accredited college, university or vocational school required. Current unencumbered license for the state of Ohio to practice as a Registered Nurse (RN). Experience One year of clinical experience in a hospital, long term care facility, or other related health care facility preferred. Supervisory experience in a long-term care, hospital, or other related healthcare setting preferred. Proficiency with electronic medical records (EMR) preferred. Other Requirements Must be able to read, write, speak, and understand the English language. Working Conditions and Special Requirements Sitting - Up to 4 hours/day Standing - Up to 8 hours/day Walking - Up to 6 hours/day Lifting, transferring, pushing or pulling residents/patients or equipment/supplies - Up to 50 pounds Driving - Up to 6 hours/day Travel % / Overnight Travel - Occasional Work weekends, evenings, and holidays - As needed On-call availability - 24/7 for emergencies Subject to falls, burns from equipment, odors, and cuts - Work day Subject to residents/patients with various disease processes - Occasional May be exposed to infectious waste, disease, conditions, etc. including exposure to the AIDS and Hepatitis B viruses - Work day Risk Category for Exposure to Bloodborne Diseases - I
RN Travel Med-Surg Full-time
OneStaffMedical

Travel Med-Surg RN – Explore Your Next Career Opportunity

OneStaffMedical London, OH
Medical-Surgical nurses provide direct care to adult patients in a variety of settings and is the largest group of nurses. They provide care for patients often with multiple diagnoses, across multiple medical specialties.
RN Travel Med-Surg Full-time
OneStaffMedical

Featured Opportunity – Travel RN | Medical-Surgical Unit

OneStaffMedical London, OH
Medical-Surgical nurses provide direct care to adult patients in a variety of settings and is the largest group of nurses. They provide care for patients often with multiple diagnoses, across multiple medical specialties.
RN Med-Surg Full-time
OneStaffMedical

1. Advance Your Career – Traveling Med-Surg Registered Nurse

OneStaffMedical London, OH
Medical-Surgical nurses provide direct care to adult patients in a variety of settings and is the largest group of nurses. They provide care for patients often with multiple diagnoses, across multiple medical specialties.