Utilization Review Nurse

Quantum Health, Inc.•Dublin, OH

9d•$51,800 - $102,800•Onsite

About The Position

The Utilization Review Nurse reviews and processes medical service requests for members of Quantum Health employer groups in inpatient settings and related transitions. The role processes clinical documentation and evaluates requested services against plan language and appropriate criteria within designated time frames. It also partners with providers and facilities on discharge planning and delivers clinical service that promotes quality, medically necessary, cost-effective care. This position is located at the Dublin, Ohio campus.

Requirements

Hold an active, unrestricted, unencumbered professional license in good standing as an RN, an LPN currently employed by Quantum Health, or another licensed healthcare professional authorized to conduct assessments independently.
Where applicable, hold a Multi-State License through the relevant licensure compact; where unavailable, be willing and able to obtain and maintain additional state licenses. Required MSL and individual state licenses must be obtained within 90 days of hire and maintained as a condition of employment.
Have at least 2 years of clinical experience providing direct patient care in an inpatient hospital setting.
Make timely decisions that achieve results consistent with business goals and organizational culture.
Work independently with limited daily supervision.
Demonstrate excellent verbal and written communication skills, including effective communication with patients, physician practices, and hospital facilities.
Use critical thinking to research and identify issues.
Collaborate and interact professionally with coworkers and external stakeholders.
Demonstrate curiosity and a solution-oriented approach.
Navigate multiple computer systems and Microsoft applications effectively.
Multitask, prioritize, and adapt effectively in a fast-paced, changing environment.
Protect company and member data and comply with company ethics and policies.
Be flexible to cross-train and perform pre-certification functions as business needs require.
Work a non-standard schedule, including holidays and weekends, as departmental staffing requires.
Use a PC, Microsoft Office (Outlook, Word, Excel, and PowerPoint), Teams and Zoom, and telephones efficiently.
Demonstrate accountability and trustworthiness, follow company policies, values, and ethics, and protect sensitive data.

Nice To Haves

Experience in health management.

Responsibilities

Assess and review inpatient medical service and related transition requests against plan language and clinical criteria, conducting initial, concurrent, and retrospective reviews.
Use clinical expertise, critical thinking, and organizational workflows to make independent decisions and determinations.
Apply Quantum Health-adopted clinical criteria and document review outcomes in the authorization database.
Facilitate discharge planning during concurrent review and after discharge, including arrangements for skilled nursing, rehabilitation, long-term acute care, home infusion, home health, and other outpatient services.
Communicate request outcomes to patients, providers, facilities, and internal work groups, while promoting Quantum Health’s mission and core values.
Research vague or questionable procedures and present them to the Chief Medical Officer or Physician Peer Reviewer; notify them of potential non-certifications within required time frames.
Prepare and present high-quality medical reviews for physician collaboration and determination.
Facilitate communication with medical providers, including external review agencies.
Coordinate health management services and provide benefit and health information to patients, caregivers, providers, and facilities to support informed decisions.
Redirect out-of-network service requests to in-network providers when possible to help members obtain optimal benefits.
Identify potential high-risk, high-cost, or chronic-condition cases and refer them to the appropriate case management team; coordinate transfers for behavioral health management when appropriate.
Maintain working knowledge of Quantum Health workflows and serve as a clinical resource for work groups.
Monitor and oversee non-clinical staff activities and be available to non-clinical staff during Quantum Health business hours.
Cross-train and perform pre-certification functions as business needs require.
Perform other duties as assigned.