Pre-Cert Pharmacy Review Nurse, RN (PBM- Pharmacy experience required)

Pre-Certification Review Nurse - Pharmacy

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. Location: This position is located at our Dublin, OH campus or may work remotely anywhere in the United States of America.

What You'll Do (Essential Responsibilities)

• Clinically review all requests for provider-administered specialty medications for appropriateness
• Support providers and members in optimization of site of care for requested services
• Demonstrate and expand a working knowledge of all clinical processes, medical policy as well as relevant employer benefit plans and how to access needed information.
• Work collaboratively with Medical Directors and Pharmacists for all relevant requests
• Serve as a Subject Matter Expert (SME) for infusible and injectable medication-related services
• Communicate with members, providers, facilities, and all internal work groups regarding outcome of requests.
• Identify of members who may be appropriate for care/case management services (Complex, High cost, Transplant)
• Identify care coordination opportunities and work with operational, clinical, and customer-facing teams on as needed basis.
• All other duties as assigned.

What You'll Bring (Qualifications)

• Education: Bachelor's degree in nursing or closely related field or equivalent experience
• Licensure /Credentials : Current and active and unrestricted license as a Registered Nurse (RN) in the state of Ohio.
• Experience: Minimum of 2 years of managed care and/or direct care nursing experience required.
• Ability to obtain additional licenses, as needed (with support from Quantum Health)
• Experience with Specialty Pharmacy/Pharmaceuticals required
• Experience with Utilization Management required
• Makes clinical decisions quickly and at times decides and acts with limited information
• Excellent critical thinking skills
• Strong interpersonal, verbal and written communication skills verbal and written communication skills
• Self-directed, organized with excellent time management skills
• Excellent computer skills including Microsoft applications
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
• A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health's policies, values and ethics, and to protecting the sensitive data entrusted to us.

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.