Registered Nurse, Transplant Utilization Review

Quantum Health • Dublin, OH

5d • Hybrid

About The Position

The Registered Nurse (RN) - Transplant Utilization Review is responsible for reviewing and processing medical service requests for members of Quantum Health’s employer groups in an inpatient setting across the transplant continuum. The nurse is responsible for acquiring all clinical documentation to appropriately process the service request within the designated time frames indicated. The utilization review nurse also functions as a clinical resource to other staff on the team and within the company such as Clinical Support Coordinators, Precertification, Patient Services, Personal Care Guide nurses, and Client Engagement Services.

Requirements

• Licensure: Active license in good standing as a Registered Nurse (RN) in Ohio required.
• Education: Bachelor of Science in Nursing (BSN) preferred.
• Experience: 2+ years of clinical experience with direct patient care required
• Excellent verbal and written communication skills.
• Comfortable communicating with members and providers via phone regularly throughout the day.
• Ability to communicate effectively with members and providers in implementing clinical services; Translate complex clinical concepts for non-clinical audiences.
• 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.

Nice To Haves

• Proven clinical experience with organ and/or bone marrow transplants, preferred.

Responsibilities

• Assess and review all requests for inpatient transplant related services, requiring clinical review against Quantum Health’s adopted clinical review criteria.
• Conduct initial clinical review, concurrent review, and retrospective review.
• Utilize Quantum Health adopted clinical criteria during all aspects of the review process and document outcomes in authorization database.
• Maintain a working knowledge of all benefit plans and know where to access the needed information.
• Facilitate discharge planning process during daily concurrent review and post discharge. This includes arranging for skilled nursing care, rehabilitation, home infusion and other outpatient ancillary services.
• Communicate with patient, provider, facility, and internal work groups regarding outcome of requests, including sending of transplant notifications and/or inpatient transplant admission notifications when applicable.
• Engage with member and providers via inbound calls through the transplant phone queue; Document Interventions in the database.
• Re-direction of non-COE or out of network service requests to COE or in network whenever possible to ensure members obtain the optimum benefit.
• 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 are able to make informed health decisions.
• Identify potential cases for high risk/high cost/chronic condition and refer to the appropriate case management team.
• Notify Chief Medical Officer/Physician Peer Reviewer of all potential non-certifications within the appropriate time frames.
• Facilitate communication between medical provider including external review agencies.
• Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review.
• All other duties as assigned.

Benefits

• 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 This Job Offers

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