PCRM Senior Specialist Utilization Management

Scope of Position

This position serves as a Patient Care Resource Manager (PCRM) Senior Specialist for health plan utilization management programs and reports to the Utilization Manager. The PCRM Senior Specialist 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 utilization management. The position is tasked with ensuring highly personalized and cost-effective care for all OSU Health Plan members. The PCRM Senior Specialist is responsible for resolving escalated member/provider concerns and working with the Utilization Manager and team clinicians to provide quality assurance for our top-quality clinical programs. The PCRM Senior Specialist provides informal guidance to other care management program staff including new PCRMs.

Position Summary:

The PCRM Senior Specialist serves as a member of the service team responsible for executing and promoting the utilization management program for 70,000+ university health plan members and affiliated groups by collaborating with the members and their health care team. The PCRM Senior Specialist reports to the Utilization Manager and collaborates with directors, managers, and clinicians to ensure delivery of affordable, high quality, and personalized health care services in an accessible, patient-friendly, focused atmosphere. The PCRM Senior Specialist guides and supports PCRM Specialist Utilization Management team members. This includes the creation and ongoing maintenance of clinical onboarding materials and training manuals in collaboration with the Utilization Manager.

The PCRM Senior Specialist role involves application of in-depth conceptual and practical clinical knowledge, managing more complex, high-acuity, or account-sensitive cases. These skills are utilized to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and options to facilitate appropriate and cost-effective outcomes for health plan members, in conjunction with physician treatment plans. This role requires a knowledge of the best practices and how the Utilization Management department integrates with other departments within OSU Health Plan and OSU Medical Center. The PCRM Senior Specialist provides Utilization Management program oversight in collaboration with the Utilization Manager. This includes management of their caseload independently and coordinates assignments within the PCRM- Specialist team members. The PCRM Senior Specialist is also responsible for taking a leadership role in implementing new initiatives both within the Utilization Management Department and collaborations within OSU Health Plan and the OSU Medical Center. Examples may include, but are not limited to, initiatives involving the OSU Health Plan website, phone tree, and concierge service. This oversight also includes evaluation of clinical tools utilized by the Utilization Management department and identifying gaps and areas of improvement, acting as a liaison between clinical departments within the Health Plan and Medical Center (e.g., pharmacy, ECM, Care Coordination, PCRMS, Pre-cert, etc.), coordinating with the Utilization Management Policy Nurse to identify educational needs within the department and ensuring the materials provided meet those needs.

The PCRM Senior Specialist must exhibit superior critical thinking and problem-solving skills; solve complex problems based on the analysis of multiple sources of information; act as an advocate for health plan members and families; explain complex information to patients, family members, and other clinicians in an easily understood manner; and effectively and efficiently document health benefit information and clinical determinations. The position also assists with the development and implementation of utilization management clinical guidelines and Utilization Management departmental policies and procedures; performs self-audits, Utilization Management team audits, and quality monitoring to improve performance; recommends program and policy improvements based on current guidelines and interactions with members and providers; and works to assure appropriate medical benefit application and claims payments.

Minimum Qualifications

For Hire: Bachelor's Degree or equivalent combination of education and experience required. 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.

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.