Utilization Management Behavioral Health Nurse (Medicaid Health Systems Specialist - RN)
Columbus, OH, United States1w ago
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Skills
About the role
Lazarus 5 (MCDLZ5)
50 West Town Street
Columbus, 43215
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.
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.
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.
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.
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.
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.
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
- Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period
- Paid time off, including vacation, personal, sick leave and 11 paid holidays per year
- Childbirth, Adoption, and Foster Care leave
- Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)
- Public Retirement Systems (such as OPERS, STRS, SERS, and HPRS) & Optional Deferred Compensation (Ohio Deferred Compensation)
*Benefits eligibility is dependent on a number of factors. The Agency Contact listed above will be able to provide specific benefits information for this position.
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
- Free Dental, Vision and Basic Life Insurance premiums after completion of eligibility period
- Paid time off, including vacation, personal, sick leave and 11 paid holidays per year
- Childbirth, Adoption, and Foster Care leave
- Education and Development Opportunities (Employee Development Funds, Public Service Loan Forgiveness, and more)