RN, Registered Nurse Utilization Review Nurse

Quantum Health • Dublin, OH

11h • Hybrid

About The Position

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.

Requirements

• 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
• 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.
• #LI-HW1 #LI-Hybrid

Nice To Haves

• Experience in health management preferred

Responsibilities

• 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.

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
• Education Level: No Education Listed