Clinical Program Coordinator - Utilization Management

Scope of Position

The Clinical Program Coordinator will support the Utilization Management department at OSU Health Plan through maintenance, development, dissemination, and education of evidence-based clinical and procedural policies. This includes both internal policies and MCG guidelines.

Position Summary

The Clinical Program Coordinator is a nurse who demonstrates clinical expertise in evidence-based practice, staff education, research, collaboration with other disciplines and interdisciplinary development activities. Under the supervision of the Utilization Manager, the Clinical Program Coordinators primary functions will include researching, writing, and publishing Medical Management and Utilization Management policies. This process includes evidence review, Policy Tech application use, engagement of OSU Health Plan clinical staff in the development and utilization process, revisions, review of guidelines against organizational standards and legal/compliance requirements, final guideline preparation, verbal and written communications regarding development and delivery, utilization assessment, ongoing review and version control. The Clinical Program Coordinator is responsible for designing, delivering, and evaluating the education of the clinical staff related to internal policies and external national guidelines. This position also conducts internal audits of the clinical staff to ensure appropriate utilization of published policies and national guidelines. The Clinical Program Coordinator is responsible for maintaining and updating the Prior Authorization list based on new coding, feedback from the Utilization Management team, and changes in evidence. The number of tasks, guidelines and projects assigned to the Clinical Program Coordinator and the complexity of the assigned tasks, guidelines and projects is expected to be high. This position is expected to be self-directed.

Minimum Qualifications

For Hire:

• Required: Bachelors in nursing with current RN licensure in the State of Ohio or current RN licensure in the State of Ohio with equivalent experience
• Experience in clinical policy development and scientific literature research.
• Familiarity with national guidelines, such as CMS policies, NCCN guidelines,
• Strong organizational and project management skills.
• Excellent communication skills, both written and verbal.
• Ability to manage multiple projects with competing priorities.
• Detail-oriented and enjoy managing simultaneous projects with multiple stakeholders.
• Ability to work well both as part of a team and independently.
• Ability to work independently in a remote work environment with minimal supervision.
• Knowledge of Microsoft Office products and clinical management software.
• Willingness to learn new skills

Ongoing:

• Maintains Ohio RN license
• Work towards MCG certification
• Completes mandatory educational and health requirements
• Maintains and seeks new knowledge related to quality improvement and cost reduction, current policies, procedures, and protocols. Remains abreast of developments in core content areas of EBP.

Job Relationships

Supervisory Responsibility: None

Contacts: Clinical staff at OSU Health Plan (nurses, pharmacists, physician), interprofessional teams/colleagues within OSU Health Plan (Marketing and Communications, Customer Service, Provider Relations, Health Plan Leadership), and external clients (Third-Party Administrator, Human Resources).

Responsible to: Utilization Manager

Physical/Visual/Mental Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee must be able to:

• Ability to communicate clearly in order to carry out responsibilities in both in-person and remote (electronic) settings.
• Ability to use electronic communication and typing equipment such as computers and portable electronic devices.

Work Environment

The office work environment involves everyday risks or discomforts which require normal safety precautions, typical of such places as offices and meeting rooms (e.g., use of safe-work practices, avoidance of trips and falls, and observance of fire regulations and traffic signs).

Remote work environments, when approved by a supervisor, must comply with all OSU Health Plan policies and HIPAA regulations. No paper records or documents containing PHI should be transported home. The employee is responsible for securely transporting and maintaining OSUWMC issued laptops while in their possession. From HIPAA Privacy, IT Security, and member service points of view, work should be done in an area that is isolated from other family members and free from distractions.

Note: The above statements are intended to describe the essential functions and related requirements of persons assigned to this job. They are not intended as an exhaustive list of all job duties, responsibilities and requirements.