Utilization Review Registered Nurse (Medicaid Health Systems Specialist – RN) | Ohio Department of Medicaid


This position may be telework eligible on a hybrid basis; the selected applicant must complete the initial training period prior to being eligible to telework. All requests to telework are reviewed on a case-by-case basis and must be approved by ODM’s Chief Human Resources Officer.

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

Office: Legal Counsel

Bureau: Program Integrity

Classification: Medicaid Health Systems Specialist/RN (PN 20043106)

Job Overview

The Ohio Department of Medicaid (ODM) is seeking a Registered Nurse (RN) to be a part of our Surveillance/Utilization Review Section (SURS). SURS is charged with helping the agency review utilization of Medicaid services, detect fraud, waste and abuse and recover inappropriate payments to providers. As a Utilization Review RN, your responsibilities will include:

  • Reviewing clinical utilization of Medicaid services
  • Evaluating provider clinical compliance with state and federal Program Integrity rules
  • Evaluating provider medical documentation and billing practices for fraud, waste and abuse
  • Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies
  • Responding to provider clinical reconsideration (appeal) requests
  • Consulting on clinical matters with ODM policy units and other state agencies
  • Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans
  • Supporting hospital utilization review contract management
  • Presenting findings from clinical reviews of provider non-compliance
  • Responding to inquiries from the public, consumers, providers and other agencies

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.

The preferred candidate will take direction and work toward established goals, with high attention to detail and strong communication skills.

What’s In It For You

At the State of Ohio, we take care of the team that cares for Ohioans. We provide a variety of quality, competitive benefits to eligible full-time and part-time employees. For a list of all the State of Ohio Benefits, visit our Total Rewards website! Our benefits package includes:

Medical Coverage

  • Quality, affordable, and competitive medical benefits are offered through the Ohio Med PPO plan.

Dental, Vision and Basic Life Insurance

  • Dental, vision and basic life insurance premiums are free after one year of continuous service.

Time Away From Work and Work/Life Balance

  • Paid time off, including vacation, personal, and sick leave
  • 11 paid holidays per year
  • Childbirth/Adoption leave

Ohio Public Employees Retirement System

  • OPERS is the retirement system for State of Ohio employees. The employee contributes 10% of their salary towards their retirement. The employer contributes an amount equal to 14% of the employee’s salary. Visit the OPERS website for more information.
    Deferred Compensation


  • The Ohio Deferred Compensation program is a 457(b) voluntary retirement savings plan. Visit the Ohio Deferred Compensation website for more information.
    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 4


    Ohio Department of Medicaid

    Classified Indicator


    Bargaining Unit / Exempt

    Bargaining Unit



    Work Hours

    8:00 a.m. – 5:00 p.m.


    $30.03/per hour

    Unposting Date

    May 27, 2022, 3:59:00 AM

    Job Function


    Job Level

    Individual Contributor

    Agency Contact Information




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