RN, Pre-Certification Review Specialist

1 week ago

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

This position is a key member of our clinical team, responsible for reviewing and processing coverage determinations and utilization management reviews for specialty medications. The successful candidate will have a strong background in nursing and experience with clinical processes and workflows. They will work closely with Medical Directors and Pharmacists to provide a customer-centered experience within service level expectations.

Key Responsibilities
  • Review and process all requests for specialty medications and site of care assessments/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. Identify 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.
Requirements
  • 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

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