RN, Registered Nurse - Pre-Certification

RN, Registered Nurse - Pre-Certification Founded in 1999 and headquartered in Central Ohio, we are 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 are 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 are 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 Nurse is responsible for all aspects of the prior authorization process for members 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. This includes verbal and written engagement with members, providers, clients, third-party vendors. The Pre-certification Nurse also functions as a clinical resource to other staff in the company such as Utilization Review, Patient Services, Personal Care Guide nurses, and Client Services. The Pre-Certification nurse provides the highest level of clinical service both internally and externally to promote quality, medically necessary, cost-effective care. Location: This position is located at our Dublin, OH campus with hybrid work from home flexibility. What you’ll do (Essential 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 outcome of requests. Coordinate health management services to provide integrated health services for each patient and 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. Communicates and works effectively with colleagues and other teams within the organization. Utilize subject matter expertise, critical thinking, and clinical knowledge to render independent decisions and determinations, following Quantum Health workflows. Direct out of network requests to in-network providers to ensure members secure the 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 as it related to the pre-certification process. Act as 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 and be available to non-clinical staff during Quantum Health’s business hours. 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 including external review agencies. Notify Chief Medical Officer/Physician Peer Reviewer of all requests you are unable to certify within specified time frames. All other duties as assigned. What you’ll bring (Qualifications) License/Certification: Current and 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. Experience: Minimum of two years clinical experience with direct patient care required in a hospital setting Experience in health management preferred 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 Ability to make decisions that are timely and achieve results consistent with business goals and organizational culture 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. 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. #J-18808-Ljbffr