Care Manager - Enhanced Case Management

The Ohio State University

1d•Onsite

About The Position

The Clinical Operations Department is responsible for all OSU Health Plan medical and pharmacy benefits and the development, execution, and evaluation of clinical programs that provide quality and cost-effective care to health plan members. This position serves as a Care Manager for health plan nursing care management programs and reports to the CM Manager. The Care Manager is responsible for delivering superior customer service and achieving clinical and operational excellence as it relates to the implementation and execution of OSU Health Plan medical/pharmacy benefits and clinical programs (i.e., Care Coordination, Enhanced Case Management, Buckeye Baby). The position is tasked with ensuring highly personalized, innovative, and cost-effective services for all OSU Health Plan members. The Care Manager is responsible for resolving escalated member/provider concerns and working with the CM Manager and team clinicians to provide quality assurance for our top-quality clinical programs. The Care Manager may manage members across the lifespan, including pediatric patients with complex acute/chronic conditions and complex medical/developmental/psychosocial needs, and collaborates with family members, caregivers, community agencies, and specialty providers as appropriate. The Care Manager provides informal guidance to other care management program staff including new PCRMs. The Care Manager serves as a member of the service team responsible for executing and promoting care management programs for university health plan members and affiliated groups by collaborating with the members and their health care team. The Care Manager reports to the CM Manager and works collaboratively with directors, managers, and clinicians to ensure delivery of differentiated affordable, high-quality, and personalized health care services in an accessible, patient-friendly, focused atmosphere. The Care Manager guides and supports new CM team members. The Care Manager utilizes expanded conceptual and practical disease state knowledge to manage a caseload of moderate to high-risk adult and pediatric patients with acute/chronic conditions and complex medical/psychosocial needs; exercises clinical process, critical thinking, and problem-solving skills to collaborate with members, providers, practice managers, and internal clinicians to solve benefit issues in an accurate and timely manner and ensure members receive high-level care throughout the care continuum; collaborates to facilitate safe and timely discharge planning in the acute and post-acute setting, including but not limited to the following settings: acute inpatient hospitalization, LTACH, skilled nursing facility, home health care, hospice; identifies opportunities and resources to address health care needs; performs clinical review and utilization management activities as necessary; documents clinical review findings and authorization determinations; collaborates with other departments including Health Plan Provider Relations team to execute Single Case Agreements outside of network; develops and maintains effective working relationships across the health care system to support efficiency; advocates for members and families by helping them to coordinate care and navigate resources throughout the health care system; explains complex information to patients, family members, and other clinicians while working to build consensus on treatment plans; effectively and efficiently documents treatment plans and outcomes; works independently with moderate guidance. The Care Manager assists with development and implementation of medical guidelines and departmental policies and procedures; performs self-audits and quality monitoring to improve performance; recommends program/policy improvements based on current guidelines; develops and maintains knowledge of health plan policies, benefit interpretation, medical necessity criteria, and utilization management guidelines; works to assure appropriate medical benefit application and claims payments; serves as a resource for colleagues with less experience.

Requirements

Current State of Ohio Registered Nurse (RN) license required
Bachelor's Degree in Nursing from an accredited program required
2 years of relevant experience required
Excellent verbal and written communication skills
Strong customer service, interpersonal, conflict resolution, problem-solving and program planning skills
Strong technology skills
Ability to work effectively with all levels of the organization
Ability to work independently on assigned projects
Ability to analyze and interpret data and organize data into actionable process improvements required
Experience with health plan policies and medical terminology required

Nice To Haves

Master’s degree preferred
Certified Case Manager (CCM) or other nationally recognized case management certification desired
Minimum of five (5) years of combined experience in multiple areas including acute care nursing, discharge planning, home health, hospice, community-based services, utilization review, disease management, or other relevant practice
Demonstrated experience coordinating care across the health care continuum, including hospitals, skilled nursing facilities (SNFs), long-term acute care hospitals (LTACHs), home health, hospice, and community-based organizations is preferred
Strong understanding of disease processes, care continuums, expected patient outcomes, evidence-based treatment modalities, and available community resources
Experience working with adult and pediatric populations with complex health needs and multiple chronic conditions preferred
Pediatric nursing, pediatric case management, pediatric specialty care, or community-based pediatric care coordination experience strongly desired
Knowledge of evidence-based clinical guidelines and utilization management criteria (e.g., MCG, InterQual) is highly desired

Responsibilities

Delivering superior customer service and achieving clinical and operational excellence.
Implementing and executing OSU Health Plan medical/pharmacy benefits and clinical programs.
Ensuring highly personalized, innovative, and cost-effective services for all OSU Health Plan members.
Resolving escalated member/provider concerns.
Providing quality assurance for clinical programs.
Managing members across the lifespan, including pediatric patients with complex conditions.
Collaborating with family members, caregivers, community agencies, and specialty providers.
Providing informal guidance to other care management program staff.
Executing and promoting care management programs for university health plan members and affiliated groups.
Collaborating with members and their health care team.
Guiding and supporting new CM team members.
Managing a caseload of moderate to high-risk adult and pediatric patients.
Exercising clinical process, critical thinking, and problem-solving skills.
Collaborating with members, providers, practice managers, and internal clinicians to solve benefit issues.
Facilitating safe and timely discharge planning in acute and post-acute settings.
Identifying opportunities and resources to address health care needs.
Performing clinical review and utilization management activities.
Documenting clinical review findings and authorization determinations.
Collaborating with other departments to execute Single Case Agreements outside of network.
Developing and maintaining effective working relationships across the health care system.
Advocating for members and families by helping them coordinate care and navigate resources.
Explaining complex information to patients, family members, and other clinicians.
Building consensus on treatment plans.
Documenting treatment plans and outcomes.
Assisting with development and implementation of medical guidelines and departmental policies and procedures.
Performing self-audits and quality monitoring to improve performance.
Recommending program/policy improvements.
Developing and maintaining knowledge of health plan policies, benefit interpretation, medical necessity criteria, and utilization management guidelines.
Assuring appropriate medical benefit application and claims payments.
Serving as a resource for colleagues with less experience.