Care Manager - Enhanced Case Management

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## Job Title:
Care Manager - Enhanced Case Management

Department:

Scope of Department

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.

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Scope of Position

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.

Position Summary:

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 management certification desired. 2 years of relevant experience required.

Preferred: 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, along with 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.

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. Knowledge of evidence-based clinical guidelines and utilization management criteria (e.g., MCG, InterQual) is highly desired.

Additional Information:

## Location:
Ackerman Rd, 700 (0921)

## Position Type:
Regular

## Scheduled Hours:
40

Shift:

Final candidates are subject to successful completion of a background check.  A drug screen or physical may be required during the post offer process.

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