Utilization Management Behavioral Health Nurse (Medicaid Health Systems Specialist - RN)

What You Will Do At ODM Office: Health Innovation & Quality Bureau: Clinical Operations/Utilization Management Classification: Medicaid Health Systems Specialist RN (PN 20046588) Pay rate: $36.01/hour Job Overview As the Utilization Management Behavioral Health Nurse in the Bureau of Clinical Operations, Ohio Department of Medicaid (ODM), your responsibilities will include: Review Clinical Coverage Policies (CCPs) to ensure service requests meet medical necessities, benefit coverage rules, and applicable Ohio Administrative Code standards. Conduct validation of service decisions, including assessing whether requested behavioral health services meet required clinical criteria and documentation thresholds; verifying completeness of assessments, treatment plans, and prior authorization submissions in alignment with UM policy requirements. Assist with rules language by interpreting behavioral health service rules and CCP requirements; helping refine, clarify, or apply rule language during reviews and provider communications; ensuring decisions reflect correct interpretation of policy, coverage rationale, and service thresholds. Participate in cross-team collaboration with medical directors, reviewers, policy teams, and behavioral health leads to ensure UM consistency and alignment with statewide managed care requirements. Support provider education by identifying policy gaps, common documentation issues, or rule misinterpretations and communicating them through appropriate UM channels. 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. For this position, besides required 24 months experience in nursing you would need to have additional 24 months experience in Behavioral Health 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 and Behavioral Health Nursing Professional Skills: Critical Thinking, Collaboration, Attention to Detail, Organizing and Planning, Verbal Communication, Written Communication, Confidentiality, Analyzation Agency Contact Name and Information View email address on click.appcast.io Unposting Date Oct 12, 2026, 11:59:00 PM Work Location Lazarus 5 Primary Location United States of America-OHIO-Franklin County-Columbus Schedule Full-time Work Hours 8:00 am - 5:00 pm Classified Indicator Classified Union 1199 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 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. #J-18808-Ljbffr Ohio Department of Medicaid