Pre-Certification Review Nurse

2 weeks ago


Dublin, Ohio, United States quantum-health Full time
About the Role

The Pre-Certification Review Nurse - Pharmacy is a critical member of our clinical team, responsible for reviewing and processing coverage determinations and utilization management reviews for specialty medications. This role requires a strong working knowledge of clinical processes and workflows, as well as employer benefit plans.

Key Responsibilities
  • Review and process all requests for specialty medications and site of care assessments.
  • Maintain a working knowledge of all clinical processes and workflows, as well as all employer benefit plans.
  • 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, providers, facilities, and internal work groups regarding the outcome of requests.
  • Identify care coordination opportunities and work with clinical teams as needed.
Requirements
  • Active license as a Registered Nurse (RN) in the state of Ohio.
  • 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.
  • Strong working knowledge of Network Medical guidelines.
  • Experience with Specialty Pharmacy/Pharmaceuticals preferred.
  • 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.
What We Offer
  • Competitive base and incentive compensation.
  • Health, vision, and dental benefits, featuring our best-in-class healthcare navigation services.
  • 401(k) plan with up to 4% employer match and full vesting on day one.
  • Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
  • Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings, and leadership development.


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