O
Clinical Quality Oversight Nurse (Medicaid Health Systems Specialist - RN) in Bexley, OH
Job Description
What You Will Do At ODM
Office: Health Innovation & Quality
Bureau: Clinical Operations
Classification: Medicaid Health Systems Specialist RN (PN 20046588)
Pay rate: $34.96/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.
• Or for positions other than those requiring valid license as registered nurse, 24 months experience as Medicaid Health Systems Analyst, (65291) 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
Professional Skills: Critical Thinking, Collaboration, Attention to Detail, Organizing and Planning, Verbal Communication, Written Communication, Confidentiality, Analyzation
Organization
Medicaid
Agency Contact Name and Information
HumanResources@medicaid.ohio.gov
Unposting Date
Feb 1, 2026, 11:59:00 PM
Work Location
Lazarus 5
Primary Location
United States of America-OHIO-Franklin County-Columbus
Compensation
$34.96/hour
Schedule
Full-time
Work Hours
8:00 am - 5:00 pm
Classified Indicator
Classified
Union
1199
Primary Job Skill
Nursing
Technical Skills
Nursing
Professional Skills
Analyzation, Attention to Detail, Collaboration, Critical Thinking, Organizing and Planning, Verbal Communication, Written Communication, Confidentiality
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
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.
Office: Health Innovation & Quality
Bureau: Clinical Operations
Classification: Medicaid Health Systems Specialist RN (PN 20046588)
Pay rate: $34.96/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.
• Or for positions other than those requiring valid license as registered nurse, 24 months experience as Medicaid Health Systems Analyst, (65291) 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
Professional Skills: Critical Thinking, Collaboration, Attention to Detail, Organizing and Planning, Verbal Communication, Written Communication, Confidentiality, Analyzation
Organization
Medicaid
Agency Contact Name and Information
HumanResources@medicaid.ohio.gov
Unposting Date
Feb 1, 2026, 11:59:00 PM
Work Location
Lazarus 5
Primary Location
United States of America-OHIO-Franklin County-Columbus
Compensation
$34.96/hour
Schedule
Full-time
Work Hours
8:00 am - 5:00 pm
Classified Indicator
Classified
Union
1199
Primary Job Skill
Nursing
Technical Skills
Nursing
Professional Skills
Analyzation, Attention to Detail, Collaboration, Critical Thinking, Organizing and Planning, Verbal Communication, Written Communication, Confidentiality
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
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.
Job Details
Medical Speciality
Public health
Employment Type
Full-time
Required License
RN (Registered Nurse)
Work Setting
Office
Similar Jobs
Amber Care•Darby, OH•1 weeks ago
Molina Healthcare•Beechwood Trails, OH•1 weeks ago
Molina Talent Acquisition•Bexley, OH•1 weeks ago