Clinical Financial Case Manager | OSU Health Plan

Scope of Department

The Wellness Department is responsible for OSU Health Plan health and wellness services along with the development, execution, evaluation and enhancement of all programming that prioritizes preventive health and well-being care as well as delivering programs available to health plan members and all benefits eligible employees. Programming prioritizes short and long term behavior change and the adoption of healthy lifestyle habits that include Primary Care, Care Coordination, Health Coaching and Buckeye Baby referrals where applicable.

Scope of Position

The Clinical Financial Case Manager is responsible for delivering superior customer service and achieving operational excellence as it relates to the implementation and execution of OSU Health Plans health and wellness benefits and programming along with referrals to clinical programs specific to their personal health needs. The Clinical Financial 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 maximizing member/employee engagement to improve short and long-term health by working with the Director of Health and Wellness along with nurses, health coaches, engagement specialist and other clinical departments throughout the OSUHP to ensure access to timely and top-quality health care programs and services. This role also assists with resolving escalated member/provider concerns and working with OSUHP colleagues that provide top-quality clinical programs and services.

Position Summary:

The Clinical Financial Case Manager 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 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 the primary escalation point for resolution of simple to complex health care and wellness benefit issues. The Clinical Financial Case Manager acts as the lead resource to nurse care coordinators, nurse case managers, pharmacists, wellness nurses, health coaches, engagement specialist 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 and internal clinicians to solve complex benefit issues and ensure members receive high level care throughout the care continuum. This position focuses on prioritizing education related to health care benefits for well care and sick care. The Clinical Financial Case Manager manages the outreach and engagement process for the OSU Health Plans high risk populations that are often impacted by social determinants of health (SDoH), health literacy and technology challenges. They work in partnership with the Clinical Financial Case Manager focused on the OSU Health Plans Buckeye Baby and Care Coordination programs including, but not limited to, re-scheduling and in-person/email/phone/mail notifications and operational aspects of the documentation and participation audit process to help ensure integrity of program data. This position also serves as a representative interacting in person and on-site with members and providers ensuring the success of OSU Health Plans 48-hour access program. The Clinical Financial Case Manager proactively responds with initiatives to enhance the member experience and ensure efficient and effective resource utilization. This position will work closely with colleagues to maintain competency with OSU Health Plan policies, procedures, and medical terminology as it relates to the care of health plan members. This position prioritizes in-person engagement with OSU employees when needed as members may experience health literacy, ESL and limited access to technology.

Duties and Responsibilities

Manages the Member Experience

• Serve as key contact and ongoing resource to health and wellness benefits as well as connection to disease management specific nurse care coordinators, nurse case managers, pharmacists, and other internal departments by providing information and assistance in managing simple to complex member and provider issues

• Obtains necessary information from member/provider/vendor to help resolve simple to complex medical and pharmacy benefit issues

• Cultivates a patient-service mentality among colleagues to enhance member satisfaction and acts as an internal consultant for optimal member satisfaction

• Meets people where they are by providing in-person assistance that includes assessing social determinants of health (SDoH) and health literacy needs.

• Work with the Health Plan Care Coordination Nurses, Health Coaches, Wellness Nurses and Enhanced Case Managers to follow-up with specific members as requested by these teams to address unmet medical and social needs

• Attend team meetings at the Health Plan/virtually to coordinate care for these populations and to develop care plans for members

• Intervenes in difficult and sometimes highly emotional situations to help alleviate member concerns and resolve perceived issues

• Receives and investigates concerns, problem solves situations, takes action or refers issues to individual or department for appropriate resolution and implements service recovery approaches.

• Documents and tracks complaints for inclusion into database for outcomes tracking on future process improvement opportunities.

• Conducts training programs for front line customer service and other clinical team members regarding SDoH.

• 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.

Manages Outreach and Engagement process for all YP4H, Health Coaching, Care Coordination and Buckeye Baby programs prioritizing preventive health screenings, well-being and disease management enrollment where applicable.

• Manages the in person outreach and engagement process for Health and Wellness related programs along with Buckeye Baby and Care Coordination programs including re-scheduling and email/phone/mail notifications when needed.

• Manages operational aspects of the documentation and participation audit process to help ensure integrity of program data

• Prepares monthly, quarterly, and yearly reports to assist with program evaluation

• Engages with OSUHP clinical program staff to review trends, outcomes and develop strategies for improving program

Attends in person team/department meetings and provides ongoing benefit education while formally addressing SDoH and health literacy challenges.

• Establish relationships with campus managers in order to facilitate an on-campus presence. This is a new role and will require relationship building.

• Educating members on the need for regular health care and assisting members in obtaining the resources necessary to meet these health care needs.

• Establishing relationships with Health Plan members that will allow the Resource Case Manager to work with the member to address their unmet health care needs. This will include regularly engaging with members at the workplace, on the phone, and even accompanying members to doctors visits when appropriate.

• Help patients address barriers to care including, but not limited to, transportation, language/literacy barriers, scheduling conflicts, food insecurity etc.

Other duties

• Recommends and develops wellness and disease management programs to enhance the member/provider experience

• Helps create program content and educational materials for OSU Health Plan programs

• Plans and participates in programming events to market OSU Health Plan programs, including but not limited to, Health and Wellness programs, Buckeye Baby, Care Coordination, and other YP4H programs that support whole person health.

• Plays a leadership role in the orientation of new staff and the maintenance of orientation materials

Minimum Requirements

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

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

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

• Experience with health plan policies and medical terminology preferred.

• Community Health Worker experience preferred.

• 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 multiple 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!