Care Manager - Enhanced Case Management

Ohio State University; United States; Sur place; USD 65 000 - 95 000; Plein temps

Résumé du poste

The Ohio State University is seeking a Care Manager - Enhanced Case Management to support the OSU Health Plan and affiliated groups. This role focuses on delivering high-quality, personalized care coordination for both adult and pediatric members, with attention to complex medical and psychosocial needs.

You will collaborate with health care teams to implement care management programs, promote clinical guidelines, and advocate for patients and families while navigating resources across the

Responsabilités

• Deliver superior customer service and achieve clinical and operational excellence in care management.
• Manage a caseload of moderate to high-risk adult and pediatric patients with acute/chronic conditions.
• Collaborate with families, caregivers, providers, practice managers, and internal clinicians to coordinate care and resolve issues.
• Facilitate safe and timely discharge planning across settings: acute inpatient, LTACH, SNF, home health care, hospice.
• Explain complex information to patients and families and build consensus on treatment plans.

Description du poste

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Job Title:

Care Manager - Enhanced Case Management

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.

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; recommended program/policy improvements based on current guidelines; develops and maintains knowledge of health plan policies, benefit interpretation, medical necess