Clinical Authorization Review Nurse (Medicaid Health Systems Specialist – RN) | Ohio Department of Medicaid

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About Us

The Ohio Department of Medicaid (ODM) is committed to improving the health of Ohioans and strengthening communities and families through quality care. ODM is implementing the next generation of Ohio Medicaid to fulfill its bold, new vision for Ohio’s Medicaid program – focusing on the individual rather than the business of managed care.

The goals of the next generation of Ohio Medicaid are:

  • Emphasize a personalized care experience
  • Improve care for children and adults with complex behavioral health needs
  • Improve wellness and health outcomes
  • Support providers in better patient care
  • Increase program transparency and accountability

What You Will Do At ODM

Working Title: Clinical Authorization Review Nurse

Classification: Medicaid Health Systems Specialist RN (PN 20099130)

Office: Health Innovation & Quality

Bureau: Clinical Operations

Pay rate: $30.93/per 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.

Current & valid license to practice professional Nursing as a Registered Nurse (i. e., RN) in Ohio as issued by the Board of Nursing pursuant to Sections 4723.03 to 4723.09, inclusive of Ohio Revised Code; additional 24 months of experience in Nursing.

Training & Development Required to Remain in Classification After Employment: Biennial renewal of license in practice as Registered Nurse per Section 4723.24 of Ohio Revised Code.

Primary Location

United States of America-OHIO-Franklin County-Columbus

Work Locations

Lazarus 5


Ohio Department of Medicaid

Classified Indicator


Bargaining Unit / Exempt

Bargaining Unit



Work Hours

8:00 a.m. – 5:00 p.m.


$30.93/per hour

Unposting Date

Mar 8, 2023, 11:59:00 PM

Job Function


Agency Contact Name

ODM Human Resources

Agency Contact Information