Care Manager - Enhanced Case Management

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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.

Minimum Requirements: Current State of Ohio Registered Nurse (RN) license required;
Bachelor's Degree in Nursing from an accredited program required; master’s degree preferred. Certified Case Manager (CCM) or other nationally recognized case…