Senior Patient Care Resource Manager

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 Senior Patient Care Resource Manager for health plan nursing care management programs and reports to the PRCM Manager. The Senior Patient Care Resource 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 Senior Patient Care Resource Manager is responsible for resolving escalated member/provider concerns and working with the PCRM Manager and team clinicians to provide quality assurance for our top-quality clinical programs. The Senior Patient Care Resource Manager assists with program policy development and implementation, provides guidance and acts as a resource to other care management program staff including PCRMs.

Position Summary:

The Senior Patient Care Resource Manager serves as a senior member of the service team responsible for developing, executing, evaluating, and promoting care management programs for approximately 74,000+ university health plan members and affiliated groups by collaborating with the members and their health care team. The Senior Patient Care Resource Manager reports to the PCRM 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 Senior Patient Care Resource Manager guides and supports PCRM team members.

The Senior Patient Care Resource Manager utilizes in-depth conceptual and practical disease state knowledge to manage a caseload of moderate to very high risk patients with acute/chronic conditions and complex medical/psychosocial needs; exercises superior clinical process, critical thinking, and problem solving skills to collaborate with members, providers, practice managers, and internal clinicians to solve complex 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; finds creative solutions to address healthcare needs; collaborates with other departments including Health Plan Provider Relations team to execute Single Case Agreements outside of network; establishes key linkages across the healthcare system to promote efficiency; advocates for members and families by helping them to coordinate care and navigate resources throughout the healthcare system; explains difficult or sensitive 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 minimal guidance.

The Senior Patient Care Resource Manager develops and assists with implementation of medical guidelines and departmental policies and procedures; performs self-audits and quality monitoring to identify compliance and quality improvement opportunities and recommend program/policy improvements based on current guidelines; works to assure appropriate medical benefit application and claims payments; serves as a resource for colleagues with less experience.

Minimum Qualifications

For Hire: Bachelor's degree or equivalent combination of education and experience required; masters preferred. State of Ohio Registered Nurse license required. Minimum of 3-5 years of experience in medical/surgical, case management, telephonic nursing, disease management, discharge planning, care coordination, or utilization review or other relevant practice; 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 required. Experience with health plan policies and medical terminology required.