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RN, Pre-Certification Review
2 months ago
Description
Location: This position is located at our Dublin, OH campus with hybrid flexibility.
Who we are
Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.
We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement.
About the role
The Pre-Certification Review Nurse – Pharmacy is responsible for reviewing and processing coverage determinations and utilization management reviews for specialty medications, to include site of care assessments, for enrollees of Quantum Health’s employer groups. The nurse is responsible for acquiring all clinical documentation to appropriately process the service request within the designated time frames indicated. A successful individual will apply critical thinking to achieve proper clinical decisions when performing clinical reviews. The role requires use of multiple systems, acquisition of all relevant clinical documentation, and other clinical resources to achieve proper decisions in utilization management reviews. The Pre-Certification Review Nurse – Pharmacy will work and collaborate with a multi-disciplinary clinical team of Pharmacists and Medical Directors to provide a customer-centered experience within service level expectations.
What you’ll do
Review and process all requests for specialty medications and site of care assessment/transitions.
Maintain a working knowledge of all clinical processes and workflows, as well as all employer benefit plans and how to access needed information.
Work with Medical Director/Physician reviewer and Pharmacy Services team for all requests requiring physician review.
May serve as a Subject Matter Expert (SME) for a clinical process or content area.
Communicate with members, provider, facility, and all internal work groups regarding outcome of requests. Identification of members who may be appropriate for case management services (Complex, High cost, Transplant)
Identify care coordination opportunities and work with clinical teams on as needed basis.
All other duties as assigned.
What you’ll bring
Active license as a Registered Nurse (RN) in the state of Ohio. Licensed Practical Nurses (LPNs) currently employed by Quantum Health may also be considered.
Bachelor’s degree in nursing or closely related field or equivalent experience
Minimum of 2 years of direct care nursing experience
Ability to obtain additional licenses, as needed (with support from Quantum Health)
Strong working knowledge of Network Medical guidelines
Experience with Specialty Pharmacy/Pharmaceuticals preferred
Makes clinical decisions quickly and at times decides and acts with limited information
Excellent critical thinking skills
Strong interpersonal skills
Excellent verbal and written communication skills
Self-directed, organized with excellent time management skills
Excellent computer skills including Microsoft applications
Protect and take care of our company and member’s data every day by committing to work within our company ethics and policies
Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
Trustworthy and accountable behavior, capable of viewing and maintaining confidential information daily.
#LI-HW #LI-Hybrid
What’s in it for you
Compensation: Competitive base and incentive compensation
Coverage: Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption assistance, EAP, Teladoc services and more.
Retirement: 401(k) plan with up to 4% employer match and full vesting on day one.
Balance: Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
Development: Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings and leadership development.
Culture: Recognition as a Best Place to Work for 15+ years, dedication to diversity, philanthropy and sustainability, and people-first values that drive every decision.
Environment: A modern workplace with a casual dress code, open floor plans, full-service dining, free snacks and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room, notary and dry-cleaning services and more
What you should know
Internal Associates: Already a Healthcare Warrior? Apply internally through Jobvite.
Process: Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check.
Diversity, Equity and Inclusion: Quantum Health welcomes everyone. We value our diverse team and suppliers, we’re committed to empowering our ERGs, and we’re proud to be an equal opportunity employer .
Tobacco-Free Campus: To further enable the health and wellbeing of our associates and community, Quantum Health maintains a tobacco-free environment. The use of all types of tobacco products is prohibited in all company facilities and on all company grounds.
Compensation Ranges: Compensation details published by job boards are estimates and not verified by Quantum Health. Details surrounding compensation will be disclosed throughout the interview process. Compensation offered is based on the candidate’s unique combination of experience and qualifications related to the position.
Sponsorship: Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.
Agencies: Quantum Health does not accept unsolicited resumes or outreach from third-parties. Absent a signed MSA and request/approval from Talent Acquisition to submit candidates for a specific requisition, we will not approve payment to any third party.
Reasonable Accommodation: Should you require reasonable accommodation(s) to participate in the application/interview/selection process, or in order to complete the essential duties of the position upon acceptance of a job offer, click here to submit a recruitment accommodation request.
Recruiting Scams: Unfortunately, scams targeting job seekers are common. To protect our candidates, we want to remind you that authorized representatives of Quantum Health will only contact you from an email address ending in @quantum-health.com. Quantum Health will never ask for personally identifiable information such as Date of Birth (DOB), Social Security Number (SSN), banking/direct/tax details, etc. via email or any other non-secure system, nor will we instruct you to make any purchases related to your employment. If you believe you’ve encountered a recruiting scam, report it to the Federal Trade Commission and your state’s Attorney General.
