Utilization Management Section Chief - RN (Medicaid Health Systems Administrator 2 - RN)

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

What You Will Do At ODM

Office

Health Innovation & Quality

Bureau

Clinical Operations/Utilization Management

Classification

Medicaid Health Systems Administrator 2 (PN: 20086630)

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

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

Work Location

Lazarus 4

Primary Location

United States of America-OHIO-Franklin County-Columbus

Compensation

$44.38/hour

Schedule

Full-time

Work Hours

8:00 am - 5:00 pm

Classified Indicator

Classified

Union

Exempt from Union

Technical Skills

Health Administration, Nursing

Professional Skills

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

Agency Overview

About Us: 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

• 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.