Pre-Certification Nurse

Quantum Health, Inc. • Dublin, OH

9d • $51,800 - $102,800 • Hybrid

About The Position

The Pre-Certification Nurse is part of a cross-functional team that advocates for members by reviewing and processing medical service requests and coordinating with providers. The role supports accurate, timely processing of clinical documentation and uses clinical review criteria to assess inpatient service requests. The position also coordinates health management services and discharge planning, helps members and providers make informed decisions, and identifies cases that may benefit from case management. Quantum Health provides a training program for the role. This position is based at the Dublin, Ohio campus with hybrid flexibility.

Requirements

• Hold an active, unrestricted, unencumbered professional license in good standing in an applicable clinical discipline: Registered Nurse (RN), Licensed Practical Nurse (LPN) currently employed by Quantum Health, or another licensed healthcare professional authorized to conduct an assessment independently.
• Where applicable, hold a Multi-State License issued through the relevant licensure compact. Where an MSL is unavailable or has not launched for the discipline, be willing and able to obtain and maintain additional state licenses as required. Required MSL and individual state licenses must be obtained within 90 days of hire and maintained.
• At least 2 years of clinical experience providing direct patient care in a hospital setting.
• Strong administrative and technical skills, including the ability to use a PC, Microsoft Office, Teams, Zoom, and telephones efficiently.
• Excellent verbal and written communication skills.
• Comfort communicating regularly by phone with members and providers throughout the day.
• Trustworthy and accountable behavior, including the ability to view and maintain confidential personal information.
• Ability to communicate effectively with members and providers when implementing clinical services and to translate complex clinical concepts for non-clinical audiences.
• Must be legally authorized to work in the United States permanently and on an ongoing basis without requiring sponsorship.

Responsibilities

• Assess and review requests for inpatient medical services requiring clinical review against Quantum Health’s adopted clinical review criteria.
• Coordinate integrated health management services for patients and provide benefit and health information to patients, caregivers, providers, and facilities.
• 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 when possible to help members maximize benefits.
• Research vague or questionable procedures and present findings to the Chief Medical/Physician Peer Reviewer for an opinion.
• Provide timely notification of potential non-certifications.
• Identify potential high-risk, high-cost, and chronic-condition cases and make appropriate recommendations to Case Management.
• Coordinate with providers, facilities, and internal partners regarding outcomes.
• Communicate clinical messages to members with empathy and patience.
• Monitor and oversee non-clinical staff activities and provide clinical support during business hours.
• Perform other duties as assigned.

Benefits

• Competitive base pay, incentive plans, and employee referral bonuses.
• Health, vision, and dental coverage, along with life insurance, legal and identity protection, adoption assistance, EAP, and Teladoc services.
• 401(k) plan with up to 4% employer match and full vesting on day one.
• Paid time off, 7 paid holidays, parental leave, volunteer days, and paid sabbaticals.
• Tuition reimbursement up to $5,250 annually, certification and continuing education reimbursement, discounted higher education partnerships, paid trainings, and leadership development.
• Modern workplace amenities including full-service dining, free snacks and drinks, a complimentary 24/7 fitness center with group classes, outdoor walking paths, a game room, notary services, and dry-cleaning services.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed