Registered Nurse, Pre-Certification Review Pharmacy

Quantum Health, Inc. • Dublin, OH

1d • $59,500 - $118,100

About The Position

The Pre-Certification Review Nurse - Pharmacy reviews and processes coverage determinations and utilization management reviews for specialty medications, including site-of-care assessments, for enrollees of Quantum Health employer groups. The nurse obtains relevant clinical documentation and processes service requests within designated time frames, using critical thinking and clinical resources to make appropriate decisions. The role involves working across multiple systems and collaborating with Pharmacists and Medical Directors to provide a customer-centered experience within service level expectations. The position is based at the Dublin, Ohio campus or may be performed remotely from anywhere in the United States.

Requirements

• Bachelor's degree in nursing or a closely related field, or equivalent experience.
• Active, unrestricted, unencumbered professional license in good standing as a Registered Nurse or another licensed healthcare professional authorized to conduct assessments independently.
• Where applicable, hold a Multi-State License issued through the relevant licensure compact; where unavailable, be willing and able to obtain and maintain additional state licenses as required. Required licenses must be obtained within 90 days of hire.
• Maintain required licensure, including timely renewal and compliance with state board regulations.
• At least 2 years of managed care and/or direct care nursing experience.
• Experience with specialty pharmacy or pharmaceuticals.
• Experience with utilization management.
• Ability to obtain additional licenses as needed, with support from Quantum Health.
• Ability to make clinical decisions quickly and sometimes act with limited information.
• Excellent critical-thinking skills.
• Strong interpersonal, verbal, and written communication skills.
• Self-directed, organized, and equipped with excellent time-management skills.
• Excellent computer skills, including Microsoft applications.
• Strong administrative and technical skills, including comfort using a PC, Microsoft Office (Outlook, Word, Excel, PowerPoint), Teams, Zoom, and telephones efficiently.
• High personal accountability and trustworthiness, commitment to company policies, values, and ethics, and care in protecting sensitive data.

Responsibilities

• Clinically review requests for provider-administered specialty medications for appropriateness.
• Support providers and members in optimizing the site of care for requested services.
• Build and maintain working knowledge of clinical processes, medical policy, employer benefit plans, and how to access needed information.
• Collaborate with Medical Directors and Pharmacists on relevant requests.
• Serve as a subject matter expert for infusible and injectable medication-related services.
• Communicate request outcomes to members, providers, facilities, and internal work groups.
• Identify members who may be appropriate for care or case management services, including complex, high-cost, and transplant cases.
• Identify care coordination opportunities and work with operational, clinical, and customer-facing teams as needed.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level