RN, Registered Nurse - Utilization Review

Description

Location: This position is located at our Dublin, OH campus.

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.

About The Role

The Utilization Review Nurse is responsible for reviewing and processing medical services requests for members of Quantum Health’s employer groups in an inpatient setting and transitions in relation. The nurse is responsible for processing all clinical documentation and appropriately reviewing the services requested against plan language and appropriate criteria within the designated time frames indicated. The Utilization Review Nurse also partners with providers and facilities to assist with discharge planning. The Utilization Review Nurse provides the highest level of clinical service both internally and externally to promote quality, medically necessary, cost-effective care.

What You’ll Do

• Assess and review all requests for inpatient medical services and transitions in relation requiring clinical review against plan language and the appropriate clinical criteria. Conduct initial clinical review, concurrent review, and retrospective review.
• Utilize subject matter expertise, critical thinking, and clinical knowledge to make independent decisions and determinations, following Quantum Health workflows.
• Utilize Quantum Health adopted clinical criteria during all aspects of the review process and document outcomes in authorization database.
• Facilitate discharge planning process during concurrent review and post discharge. This includes making arrangements for skilled nursing care, rehabilitation, long term acute care, home infusion, home health care, and other outpatient services.
• Communicate with patient, provider, facility, and internal work groups regarding outcome of requests. Promote the mission and core values of Quantum Health.
• Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review. Notify Chief Medical Officer/Physician Peer Reviewer of all potential non-certifications within the appropriate time frames.
• Prepare and present high-quality medical reviews for MD collaboration and determination.
• Facilitate communication between medical providers including external review agencies.
• Coordinate health management services to provide integrated health services for each patient and provide benefit and health information to patients, caregivers, providers, and facilities so they can make informed health decisions.
• Re-direction of out of network service requests to in network whenever possible to ensure members obtain the optimum benefit.
• Identify potential cases for high risk/high cost/chronic condition and refer to the appropriate case management team. Maintain contact with internal clinical staff for transfer of cases for behavioral health management when appropriate.
• Maintain a working knowledge of all Quantum Health workflows.
• Be a clinical resource for all Quantum Health work groups.
• Provide monitoring and oversight of non-clinical staff activities and be available to non-clinical staff during Quantum Health’s business hours.
• All other duties as assigned.
  
  
  

What You’ll Bring

• 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.
• Minimum of 2 years clinical experience with direct patient care required in an inpatient hospital setting
• Experience in health management preferred
• Ability to make decisions that are timely and that achieve results consistent with business goals and organizational culture
• Works independently with limited need for daily supervision
• Possess excellent verbal and written communication skills
• Strong ability to communicate effectively with patients, physician practices, hospital facilities
• Aptitude to research and identify issues using critical thinking
• Works collaboratively and interacts professionally with coworkers and external stakeholders
• Demonstrates curiosity and a solution-oriented approach to achieving results
• Outstanding computer skills, navigating multiple systems, and Microsoft applications
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
• 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 .