Patient Care Resource Manager - Retrospective Review

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Job Title:

Patient Care Resource Manager - Retrospective Review

Department:

OSU Health Plan | Utilization Management

Scope of Department 

The Ohio State University Health Plan administers the healthcare benefits and services offered to faculty and staff at The Ohio State University. Our mission is to optimize health potential by transforming healthcare and its delivery through preventive, comprehensive, and personalized health plans, beginning with The Ohio State University and extending to surrounding communities. The Retro Patient Care Resource Manager is part of the Clinical Operations Department, which oversees all OSU Health Plan medical and pharmacy benefits, and develops clinical programs that promote quality and cost efficiency for members. Currently OSU Health Plan coordinates and evaluates health care delivery for 70,000+ health plan members.

Scope of Position

The Retro PCRM is responsible for conducting retrospective reviews of medical services to determine medical necessity, appropriateness, and compliance with established guidelines. This role also provides support to the Utilization Management team.

Position Summary

The Retro PCRM is responsible for performing retrospective reviews of inpatient, outpatient, and specialty claims to determine medical necessity and validate coding accuracy. The nurse collaborates with providers, internal departments, and external partners to ensure services rendered meet medical necessity criteria. The position also supports the Utilization Management team with prior authorization and concurrent reviews when needed. The Retro PCRM is also responsible for identifying trends and assisting in the development and implementation of related clinical guidelines and departmental policies and procedures. The nurse works to ensure appropriate benefit application and claims payments and performs other duties and responsibilities as assigned. This position requires successful completion of a background check.

Duties and Responsibilities (Include percentage of time for each section)

60% Retrospective Reviews

• Ensures medically appropriate, high-quality, cost-effective care through retrospective review of medical records.
• Utilizes clinical guidelines, benefit plan information, and industry standards to ensure accurate claims payment.
• Collaborate with members, providers, internal departments, and third-party vendors to gather necessary information for a complete record review.
• Completes complex claim reviews, including itemized bills, modifier, implant, coding reviews.
• Navigate electronic medical record and care management platforms to analyze data and requests when appropriate.
• Document findings and maintain accurate records in the electronic medical record/care management system.
• Maintain a thorough understanding of the referral process which includes prior authorization requirements, benefits, and claims payment and can independently resolve issues.
• Serves as a clinical resource for Utilization Management, Medical Director, and Appeal Coordinator
• Provides a high-level of customer service to members and providers.

15% Process improvement

• Analyze claims data to identify patterns, trends, and anomalies that may indicate inappropriate billing or utilization.
• Develop and implement action plans to address identified issues, including provider education and internal process improvements.
• Collaborate with the Third-Party Administrator, Compliance, and Provider Relations teams to ensure policies are applied consistently.
• Recognize areas of potential overutilization or underutilization and escalate concerns through appropriate channels.
• Maintain knowledge of regulatory requirements and ensure review procedures are compliant.
• Recommend policy or guideline updates based on recurring issues or regulatory changes.
• Identify opportunities for improved care coordination and cost containment based on retrospective review findings.

15% Utilization Management Support

• Provide coverage for team members during absences or high-volume periods.
• Conduct prior authorization reviews for inpatient admissions, outpatient procedures, behavioral health services, and specialty medications as needed.
• Apply evidence-based criteria (e.g., MCG) and internal policies to determine medical necessity and appropriateness of requested services.
• Communicate authorization decisions to members and providers in a timely and professional manner.
• Document all prior authorization activities in the electronic medical record/care management system, maintaining compliance with regulatory and organizational standards.
• Serve as a resource for team members regarding complex prior authorization requests.
• Support discharge planning and transitions of care as needed.
• Identify and resolve barriers that hinder effective patient care.

10% Other Duties as Assigned

• Assist with special projects or initiatives within the Utilization Management department.
• Participate in cross-functional committees or workgroups as requested.
• Contribute to staff training and mentoring when needed.
• Perform data analysis or reporting tasks to support departmental goals.

Competencies Required

Shows strong understanding and demonstrates positive behaviors associated with the following competencies:

• Clinical Expertise:
  • RN licensure required.
  • Deep understanding of medical terminology, clinical guidelines (e.g., MCG), and evidence-based practices
  • Ability to interpret medical records and apply medical necessity criteria accurately.
• Analytical Skills:
  • Proficiency in analyzing data to identify patterns, anomalies, and potential compliance issues.
  • Strong critical thinking skills for resolving discrepancies and implementing corrective actions.
• Regulatory and Compliance Knowledge:
  • Familiarity with CMS regulations, state mandates, and federal laws
  • Understanding of HIPAA privacy and security requirements
• Communication Skills:
  • Clear and professional verbal and written communication with providers, members, external vendors, and internal teams
• Technical Proficiency:
  • Skilled in utilization management systems and electronic health records (e.g., Epic)
  • Competence in Microsoft Office (Word, Excel, Outlook)
• Collaboration and Teamwork:
  • Ability to work cross-functionally.
  • Willingness to support team members during absences or high-volume periods.
• Time Management and Organization:
  • Ability to prioritize multiple tasks and meet deadlines in a demanding environment.
  • Strong attention to detail for accurate documentation and compliance
• Adaptability:
  • Flexibility to manage additional duties as assigned, including special projects and process improvement.
  • Capacity to adjust to changing regulatory requirements and organizational priorities.

Organizational Expectations 

Practices within the policies and procedures of OSU Health Plan, Wexner Medical Center, and The Ohio State University. Adheres to OSU Health Plan’s Values and Mission statements as demonstrated through positive member, patient/guest relations, positive and effective interactions with staff, and formulating and meeting developmental goals. Works in a collaborative and mutually respectful manner. Demonstrates understanding of job responsibilities and uses appropriate knowledge and skills to effectively complete work. Works effectively as a team member and maintains a positive relationship and open communication with other team members. Demonstrates a commitment to providing the highest quality of service to all customers.

Minimum Qualifications

For Hire:

• Education: Bachelor’s degree in nursing. Current Ohio Registered Nurse license.
• Experience: Minimum three years’ experience in a clinical setting required. Experience in utilization and/or case management, either with a managed care organization or provider is also required.
• Knowledge and Skills:
  • Knowledge and understanding of concepts pertaining to managed health care.
  • Ability to manage cases through the utilization review process.
  • Experience with national guidelines in determining appropriate care levels (MCG)
  • Ability to communicate effectively both orally and in writing.
  • Ability to effectively utilize Microsoft Office applications such as Outlook, Word, Excel, and other data entry processing applications.
  • Ability to evaluate medical records and other health care data.
  • Strong organization and time management skills
  • Strong knowledge of HIPAA Privacy and Security regulations

Ongoing:

• Maintain an active and unrestricted Ohio RN license.
• Maintain knowledge of OSU Health Plan’s policies and procedures and functions within those guidelines.
• Sustains maintains positive member and colleague relations.

Patient Population Served  

Knowledge of growth and development and an understanding of the range of treatments necessary to meet the age specific needs of the patient population served (Check those that apply):

Not Applicable: Non-patient care title

X

Neonates (0 - 6 months)

Adults (18 - 64 years)

Children (7 months - 13 years)

Geriatrics (65 + years)

Job Relationships

Supervisory Responsibility:   N/A

Contacts: Members, providers, clients/customers, administrative personnel, professional clinical personnel (physicians, nurses, etc.), department and division directors and managers, customer service department personnel, IS software and hardware vendor, OSU Wexner Medical Center, Office of Human Resources, external vendors

Responsible to: Utilization Manager, Director Clinical Operations

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.

Work Environment 

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

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.

Additional Information:

Location:

Remote Location

Position Type:

Regular

Scheduled Hours:

40

Shift:

First Shift

Thank you for your interest in positions at The Ohio State University and Wexner Medical Center. Once you have applied, the most updated information on the status of your application can be found by visiting the Candidate Home section of this site. Please view your submitted applications by logging in and reviewing your status. For answers to additional questions please review the frequently asked questions.

The university is an equal opportunity employer, including veterans and disability. 

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