Inside Higher Ed
Job Title
Senior Patient Care Resource Manager
Department OSU Health Plan | Care Management
Location Ackerman Rd, 700 (0921)
Position Type Regular
Scheduled Hours 40 hours per week
Shift First Shift
Responsibilities
Deliver superior customer service and achieve clinical and operational excellence in implementing and executing OSU Health Plan medical/pharmacy benefits and clinical programs.
Resolve escalated member/provider concerns and collaborate with the PCRM Manager and team clinicians to provide quality assurance for top-quality clinical programs.
Assist with program policy development and implementation, provide guidance and act as a resource to other care management program staff including PCRMs.
Manage a caseload of moderate to very high risk patients with acute/chronic conditions and complex medical/psychosocial needs, exercising superior clinical process, critical thinking, and problem‑solving skills.
Collaborate with members, providers, practice managers, and internal clinicians to solve complex benefit issues accurately and timely, ensuring members receive high‑level care throughout the care continuum.
Facilitate safe and timely discharge planning in acute and post‑acute settings, including acute inpatient hospitalization, LTACH, skilled nursing facility, home health care, hospice.
Develop and assist with implementation of medical guidelines and departmental policies and procedures; perform self‑audits and quality monitoring to identify compliance and quality improvement opportunities.
Qualifications
Bachelor’s degree or equivalent combination of education and experience required; master’s preferred.
State of Ohio Registered Nurse license required.
3‑5 years of experience in medical/surgical, case management, telephonic nursing, disease management, discharge planning, care coordination, or utilization review, with experience with home health, SNFs, LTACHs.
Advanced knowledge of current and emerging medical treatment modalities and best practice guidelines with the ability to analyze and interpret medical and benefit coverage interrelationships.
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.
Experience with health plan policies and medical terminology required.
Additional Information Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post‑offer process.
The university is an equal opportunity employer, including veterans and disability. As required by Ohio Revised Code section 3345.0216, Ohio State will: educate students by means of free, open and rigorous intellectual inquiry to seek the truth; equip students with the opportunity to develop intellectual skills to reach their own, informed conclusions; not require, favor, disfavor or prohibit speech or lawful assembly; create a community dedicated to an ethic of civil and free inquiry, which respects the autonomy of each member, holds them to equal standards and provides equality of opportunity with regard to race, ethnicity, religion, sex, sexual orientation, gender identity or gender expression.
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Department OSU Health Plan | Care Management
Location Ackerman Rd, 700 (0921)
Position Type Regular
Scheduled Hours 40 hours per week
Shift First Shift
Responsibilities
Deliver superior customer service and achieve clinical and operational excellence in implementing and executing OSU Health Plan medical/pharmacy benefits and clinical programs.
Resolve escalated member/provider concerns and collaborate with the PCRM Manager and team clinicians to provide quality assurance for top-quality clinical programs.
Assist with program policy development and implementation, provide guidance and act as a resource to other care management program staff including PCRMs.
Manage a caseload of moderate to very high risk patients with acute/chronic conditions and complex medical/psychosocial needs, exercising superior clinical process, critical thinking, and problem‑solving skills.
Collaborate with members, providers, practice managers, and internal clinicians to solve complex benefit issues accurately and timely, ensuring members receive high‑level care throughout the care continuum.
Facilitate safe and timely discharge planning in acute and post‑acute settings, including acute inpatient hospitalization, LTACH, skilled nursing facility, home health care, hospice.
Develop and assist with implementation of medical guidelines and departmental policies and procedures; perform self‑audits and quality monitoring to identify compliance and quality improvement opportunities.
Qualifications
Bachelor’s degree or equivalent combination of education and experience required; master’s preferred.
State of Ohio Registered Nurse license required.
3‑5 years of experience in medical/surgical, case management, telephonic nursing, disease management, discharge planning, care coordination, or utilization review, with experience with home health, SNFs, LTACHs.
Advanced knowledge of current and emerging medical treatment modalities and best practice guidelines with the ability to analyze and interpret medical and benefit coverage interrelationships.
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.
Experience with health plan policies and medical terminology required.
Additional Information Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post‑offer process.
The university is an equal opportunity employer, including veterans and disability. As required by Ohio Revised Code section 3345.0216, Ohio State will: educate students by means of free, open and rigorous intellectual inquiry to seek the truth; equip students with the opportunity to develop intellectual skills to reach their own, informed conclusions; not require, favor, disfavor or prohibit speech or lawful assembly; create a community dedicated to an ethic of civil and free inquiry, which respects the autonomy of each member, holds them to equal standards and provides equality of opportunity with regard to race, ethnicity, religion, sex, sexual orientation, gender identity or gender expression.
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