Utilization Case Manager

Scope of Department

The Clinical Operations Department oversees all OSU Health Plan medical and pharmacy benefits and develops clinical programs that promote quality care and cost efficiency for members.

Scope of Position

The Utilization Case Manager is responsible for delivering superior customer service and achieving operational excellence as it relates to the implementation and execution of OSU Health Plan medical/pharmacy benefits and clinical programs. The Utilization Case Manager is tasked with ensuring highly personalized, innovative, and cost-effective services for all OSU Health Plan members. This position serves as the lead in managing all incoming member/provider communication related to utilization management, resolving escalated member/provider concerns and working with the Utilization Manager and team clinicians to provide top-quality clinical programs.

Position Summary

The Utilization Case Manager collaborates with directors, managers, and clinicians to ensure delivery of differentiated, affordable, high quality and personalized health care services in an accessible, patient-friendly focused environment. The position provides concierge level services to OSU Health Plan members and providers with the goal of educating and ensuring timely and cost-effective delivery of service and serves as a primary escalation point for resolution of complex medical benefit issues. The Utilization Case Manager acts as the lead resource to nurse case managers, pharmacists, and other internal departments by providing information to assist them in managing member and provider issues while cultivating a patient-service mentality among colleagues to enhance member/provider satisfaction. This position collaborates with members, providers, practice managers, and internal clinicians to solve complex benefit issues and ensure members receive high level care throughout the care continuum. The Utilization Case Manager manages all incoming calls, faxes, and emails for the Utilization Management program including, but not limited to, operational aspects of the prior authorization and appeals processes. This position also serves as the lead representative interacting with members and providers ensuring appropriate triage within both the Utilization Management department and OSU Health Plan. The Utilization Case Manager assists with program management duties related to utilization management and appeals, such as the training and supervision of the Utilization Management student employees. This includes monitoring student schedules, attendance, and performance. The Utilization Case Manager proactively responds with initiatives to enhance the member experience and ensure efficient and effective resource utilization. This position is expected to maintain competency with OSU Health Plan and general health insurance market policies, procedures, and medical terminology as it relates to the care of health plan members

Minimum Qualifications

• Bachelor's Degree or equivalent combination of education and experience required.

• 2 years of relevant experience required. 2-4 years of relevant experience preferred.

• Health care experience desired.

• Previous experience managing projects or serving as a team lead desired.

• Experience with health plan policies and medical terminology preferred.

• LPN or MA 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.

Our Comprehensive Employee Benefits Include

• An array of retirement plan options, each with a generous employer contribution.

• Affordable health insurance options, including dental, vision and prescription coverage that begin on day one.

• Paid vacation and sick leave, including short and long-term disability and paid parental leave.

• Get the most out of the Public Service Loan Forgiveness program.

• And much more!