Care Manager - Enhanced Case Management

About the role

The Clinical Operations Department oversees all OSU Health Plan medical and pharmacy benefits and develops, executes, and evaluates clinical programs that deliver quality, cost‑effective care to health plan members. This position serves as a Care Manager for nursing care management programs, reporting to the CM Manager. The Care Manager delivers superior customer service and achieves clinical and operational excellence in the implementation and execution of OSU Health Plan medical/pharmacy benefits and clinical programs such as Care Coordination, Enhanced Case Management, and Buckeye Baby. The role ensures highly personalized, innovative, and cost‑effective services for all members, resolves escalated member and provider concerns, and works with the CM Manager and team clinicians to provide quality assurance for clinical programs. The Care Manager may manage members across the lifespan — including pediatric patients with complex acute/chronic conditions and complex medical, developmental, and psychosocial needs — and collaborates with family members, caregivers, community agencies, and specialty providers. The position also provides informal guidance to other care management staff, including new PCRMs.

As a member of the service team, the Care Manager executes and promotes care management programs for university health plan members and affiliated groups by collaborating with members and their health care teams. The role 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. Clinical process, critical thinking, and problem‑solving skills are applied to collaborate with members, providers, practice managers, and internal clinicians to resolve benefit issues accurately and timely, ensuring members receive high‑level care throughout the care continuum. The Care Manager facilitates safe and timely discharge planning in acute and post‑acute 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, documents clinical review findings and authorization determinations, and collaborates with other departments — including Health Plan Provider Relations — to execute Single Case Agreements outside the network. The position develops and maintains effective working relationships across the health care system, advocates for members and families by helping them coordinate care and navigate resources, explains complex information to patients, families, and clinicians to build consensus on treatment plans, documents treatment plans and outcomes efficiently, and works independently with moderate guidance. Additional duties include assisting with development and implementation of medical guidelines and departmental policies, performing self‑audits and quality monitoring, recommending program/policy improvements, maintaining knowledge of health plan policies, benefit interpretation, medical necessity criteria, and utilization management guidelines, assuring appropriate medical benefit application and claims payments, and serving as a resource for less‑experienced colleagues.