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

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

Organization: Medicaid Agency Contact Name and Information: View email address on click.appcast.io

Work Location: Lazarus 5 50 West Town Street Columbus 43215

Primary Location: United States of America-OHIO-Franklin County-Columbus Compensation: $36.01/hour

Schedule: Full-time Work Hours: 8:00 am - 5:00 pm Classified Indicator: Classified Union: 1199

Job Description

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.

Qualifications

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.

Technical Skills: Nursing and Behavioral Health Nursing Professional Skills: Critical Thinking, Collaboration, Attention to Detail, Organizing and Planning, Verbal Communication, Written Communication, Confidentiality, Analyzation