RN, Registered Nurse- Pre-Certification Pharmacy Review

Description

Who we are

Founded in 1999 and headquartered in Central Ohio were a privately-owned independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone and were on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted tech-savvy team fights to ensure that our members get the care they need when they need it at the most affordable cost thats why we call ourselves Healthcare Warriors.

Were committed to building diverse and inclusive teams more than 2000 of us and counting so if youre excited about this position we encourage you to apply even if your experience doesnt match every requirement.

About the role

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 Healths 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.

Location: This position is located at our Dublin OH campus with hybrid flexibility.

What youll do

• 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.

What youll bring

• 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: Bachelors 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
• Experience with Specialty Pharmacy/Pharmaceuticals preferred
• 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 members 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

Whats in it for you

• 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 $5250 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 you should know

• Internal Associates: Already a Healthcare Warrior Apply internally through Jobvite.
• Process: Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check.
• Diversity Equity and Inclusion: Quantum Health welcomes everyone. We value our diverse team and suppliers were committed to empowering our ERGs and were proud to be an equal opportunity employer .

• Tobacco-Free Campus: To further enable the health and wellbeing of our associates and community Quantum Health maintains a tobacco-free environment. The use of all types of tobacco products is prohibited in all company facilities and on all company grounds.
• Compensation Ranges: Compensation details published by job boards are estimates and not verified by Quantum Health. Details surrounding compensation will be disclosed throughout the interview process. Compensation offered is based on the candidates unique combination of experience and qualifications related to the position.
• Sponsorship: Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.
• Agencies: Quantum Health does not accept unsolicited resumes or outreach from third-parties. Absent a signed MSA and request/approval from Talent Acquisition to submit candidates for a specific requisition we will not approve payment to any third party.

Reasonable Accommodation: Should you require reasonable accommodation(s) to participate in the application/interview/selection process or in order to complete the essential duties of the position upon acceptance of a job offer click here to submit a recruitment accommodation request.

Recruiting Scams: Unfortunately scams targeting job seekers are common. To protect our candidates we want to remind you that authorized representatives of Quantum Health will only contact you from an email address ending in @. Quantum Health will never ask for personally identifiable information such as Date of Birth (DOB) Social Security Number (SSN) banking/direct/tax details etc. via email or any other non-secure system nor will we instruct you to make any purchases related to your employment. If you believe youve encountered a recruiting scam report it to the Federal Trade Commission and your states Attorney General.