RN, Registered Nurse- Pre-Certification Pharmacy Review

Quantum Health • Dublin, OH

12d • Hybrid

About The Position

The Pre-Certification Review Nurse – Pharmacy is responsible for reviewing and processing coverage determinations and utilization management reviews for specialty medications, to include site of care assessments, for enrollees 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. A successful individual will apply critical thinking to achieve proper clinical decisions when performing clinical reviews. The role requires use of multiple systems, acquisition of all relevant clinical documentation, and other clinical resources to achieve proper decisions in utilization management reviews. The Pre-Certification Review Nurse – Pharmacy will work and collaborate with a multi-disciplinary clinical team of Pharmacists and Medical Directors to provide a customer-centered experience within service level expectations.

Requirements

• 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.
• Education: Bachelor’s degree in nursing or closely related field or equivalent experience
• Experience: Minimum of 2 years of direct care nursing experience
• Ability to obtain additional licenses, as needed (with support from Quantum Health)
• Strong working knowledge of Network Medical guidelines
• Makes clinical decisions quickly and at times decides and acts with limited information
• Excellent critical thinking skills
• Strong interpersonal skills
• Excellent verbal and written communication skills
• Self-directed, organized with excellent time management skills
• Excellent computer skills including Microsoft applications
• 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.

Nice To Haves

• Experience with Specialty Pharmacy/Pharmaceuticals preferred

Responsibilities

• Review and process all requests for specialty medications and site of care assessment/transitions.
• Maintain a working knowledge of all clinical processes and workflows, as well as all employer benefit plans and how to access needed information.
• Work with Medical Director/Physician reviewer and Pharmacy Services team for all requests requiring physician review.
• May serve as a Subject Matter Expert (SME) for a clinical process or content area.
• Communicate with members, provider, facility, and all internal work groups regarding outcome of requests.
• Identification of members who may be appropriate for case management services (Complex, High cost, Transplant)
• Identify care coordination opportunities and work with clinical teams on as needed basis.
• All other duties as assigned.

Benefits

• Competitive base and incentive compensation
• 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.
• 401(k) plan with up to 4% employer match and full vesting on day one.
• Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
• Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings and leadership development.
• Recognition as a Best Place to Work for 15+ years, dedication to diversity, philanthropy and sustainability, and people-first values that drive every decision.
• 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