Pre-Certification Nurse

Quantum Health - Dublin, OH

Job Title: Pre-Certification Nurse

Position: Responsible for all aspects of the prior authorization process for members of Quantum Health’s employer groups.

Job Type:

Pay: Competitive base and incentive compensation

Shift:

Work Type: Hybrid

Location

Address:

City: Dublin

State: OH

ZIP Code:

Job Responsibilities

Assess and review all requests for medical services requiring clinical review against Quantum Health adopted clinical review criteria.
Communicate with patient, provider, facility, and internal work groups regarding outcomes of requests.
Coordinate health management services to provide integrated health services for each patient.
Provide benefit and health information to patients, caregivers, providers, and facilities to enable informed health decisions.
Identify care coordination opportunities for patients admitted for elective surgical procedures.
Communicate and work effectively with colleagues and other teams within the organization.
Utilize subject matter expertise, critical thinking, and clinical knowledge to render independent decisions and determinations.
Direct out-of-network requests to in-network providers to ensure members secure optimum desired benefits.
Facilitate the discharge planning process during pre-service review and coordinate with other clinical work teams.
Promote the mission and core values of Quantum Health by proactively managing client/member expectations.
Act as a clinical resource for all Quantum Health work groups.
Maintain a working knowledge of all Quantum Health’s workflows.
Provide monitoring and oversight of non-clinical staff activities.
Identify potential high risk/high-cost cases and chronic condition cases and refer to the appropriate case management team.
Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review.
Prepare and present high-quality medical reviews for MD collaboration and determination.
Facilitate communication between medical providers and external review agencies.
Notify Chief Medical Officer/Physician Peer Reviewer of all requests unable to be certified within specified time frames.
Perform all other duties as assigned.

Required Skills

Core Skills

Active license as a Registered Nurse (RN) in the state of Ohio or Licensed Practical Nurses (LPNs) currently employed by Quantum Health.
Minimum of two years clinical experience with direct patient care required in a hospital setting.
Strong ability to communicate effectively with patients, employer groups, and physicians.
Driven to work independently with limited need for daily supervision.
Aptitude to research and identify issues using critical thinking.
Outstanding computer skills including Microsoft applications.
Possess excellent time management skills.
Ability to make timely decisions that achieve results consistent with business goals.
Trustworthy and accountable behavior, capable of viewing and maintaining confidential information.

Preferred Skills

Experience in health management.

Requirements

Experience: Minimum of two years clinical experience with direct patient care required in a hospital setting.

Education:

License & Certification:

Registered Nurse (RN) license in the state of Ohio.
Licensed Practical Nurses (LPNs) currently employed by Quantum Health may also be considered.

Schedule:

COVID-19 Requirements: Not Specified

Benefits

Health, vision, and dental coverage.
Life insurance, legal and identity protection.
Adoption assistance and Employee Assistance Program (EAP).
Teladoc services.
401(k) plan with up to 4% employer match.
Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, and paid sabbaticals.
Tuition reimbursement up to $5,250 annually.
Certification/continuing education reimbursement.
Discounted higher education partnerships.
Paid trainings and leadership development.
Casual dress code, modern workplace with amenities such as full-service dining and fitness center.