Senior RN, Utilization Management Lead

Ohio Department of Medicaid; Columbus (OH); On-site; USD 76,300,000 - 127,166,000; Full time

Job summary

Ohio Department of Medicaid is seeking an Utilization Management Section Chief - RN to lead the UM program within the Health Innovation & Quality office, overseeing two nursing teams and vendor/managed care UM operations in Columbus, OH.

The role emphasizes policy development, data-driven reporting, and ensuring timely, medically appropriate authorization decisions by qualified clinicians, with a focus on improving member care and health outcomes.

Qualifications

• Graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance.
• 24 months of experience in planning & administering health services program or health services project management.
• Current and valid RN license to practice in Ohio.
• For RN positions, 24 months experience as a Medicaid Health Systems Administrator 1 may be substituted for the experience required, but not for licensure.
• Equivalents may be substituted for the experience required, but not for licensure.

Responsibilities

• Provide oversight to UM clinical operations, technology, quality, and regulatory oversight to advance ODM.
• Manage two teams of nurses and oversee UM of vendor and managed care entities.
• Develop reports to monitor UM goals across ODM programs.
• Oversee day-to-day operations of the Utilization Management Program across ODM programs.
• Develop and maintain written policies and procedures regarding authorization processes and monitoring of utilization management.
• Ensure consistent application of review criteria across ODM programs.
• Ensure authorization decisions are made by a clinician with appropriate expertise.
• Ensure notices of adverse action are provided and meet ODM requirements.
• Ensure authorization decisions are made within allowable timeframes.
• Evaluate under and over utilization information for impact on member care and access to care.
• Assist with onboarding and ongoing training.

Skills

Nursing

Health Administration

Critical Thinking

Collaboration

Decision Making

Verbal Communication

Written Communication

Education

Graduate degree in health administration/public health or related field

Registered Nurse (RN) license

Job description

Ohio Department of Medicaid is seeking an Utilization Management Section Chief - RN to lead the UM program within the Health Innovation & Quality office, overseeing two nursing teams and vendor/managed care UM operations in Columbus, OH.

The role emphasizes policy development, data-driven reporting, and ensuring timely, medically appropriate authorization decisions by qualified clinicians, with a focus on improving member care and health outcomes.