Pre-Certification Nurse

Job Description

Job Description

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.   

The Pre-Certification Nurse is a key member of a cross-functional team driven by their mutual devotion to serve others. They advocate for members by reviewing, processing and interfacing with providers when medical service requests are made, ensuring smooth, accurate and timely processing of clinical documentation. Quantum Health’s best-in-class training program when combined with prior direct care nursing experience makes Pre-Certification Nurses incredibly well-rounded Healthcare Warriors.   

Location: This position is located at our Dublin, OH campus with hybrid flexibility  

What you’ll do  

• Assess and review all requests for inpatient medical services requiring clinical review against Quantum Health’s adopted clinical review criteria.  

• Coordinate integrated health management services for each patient and provide benefit and health information to patients, caregivers, providers and facilities so they can make informed health decisions.  

• Facilitate the discharge process during pre-service review and coordinate with other clinical work teams.  

• Redirect out-of-network service requests to in-network providers to ensure maximum benefit to members, when possible.  

• Research vague or questionable procedures and present findings to the Chief Medical/Physician Peer Reviewer for opinion; Provide timely notification of potential non-certifications.  

• Identify potential high-risk/high-cost cases and chronic condition cases and make appropriate recommendations to Case Management.  

• Coordinate with providers, facility and internal partners regarding outcomes.  

• Effectively translate and communicate clinical messages to members with empathy and patience.  

• Provide monitoring and oversight of non-clinical staff activities and provide clinical support during business hours.  

• All other duties as assigned.  

What you’ll need  

• Licensure and Credentialing: Must hold an active, unrestricted, and unencumbered professional license in good standing with the state board of licensure in one of the applicable clinical disciplines: Registered Nurse (RN), Licensed Practical Nurses (LPNs) currently employed by Quantum Health, or other licensed healthcare professional authorized to conduct an assessment independently. Where applicable, clinicians must hold a Multi-State License (MSL) issued through the relevant licensure compact (e.g., Nurse Licensure Compact for RNs). For clinicians in states that do not offer MSL, or for disciplines for which an MSL program has not been launched, employees must be willing and able to obtain and maintain additional state licenses as required to support members served by the organization. Both the MSL and individual state licenses must be obtained within 90 days of hire. Maintenance of required licensure, including timely renewal and compliance with state board regulations, is a condition of employment. 

• 2+ years of clinical experience with direct patient care in a hospital setting required.  

• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.   

• Excellent verbal and written communication skills. Comfortable communicating with members and providers via phone regularly throughout the day.  

• Trustworthy and accountable behavior, capable of viewing and maintaining confidential personal information daily.    

• Ability to communicate effectively with members and providers in implementing clinical services; Translate complex clinical concepts for non-clinical audiences.   

What’s in it for you  

• Compensation: Competitive base pay, incentive plans and employee referral bonuses.  

• 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! Check out our home:

What you should know  

• Internal Associates: Already a Healthcare Warrior? Apply internally through Lever  

• 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.  

• 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.   

• Sponsorship: Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.  

We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistenc