RN, Registered Nurse Utilization Review

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 Utilization Review Nurse is responsible for reviewing and processing medical services requests for members of Quantum Healths 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.

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

What youll do (Essential 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 provider including external review agencies.

Coordinate health management services in an effort 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.

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 Healths business hours.

All other duties as assigned.

What youll bring (Qualifications)

Licensure: 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.

Experience: Minimum of 2 years clinical experience with direct patient care required in an inpatient hospital setting

Experience in health management preferred

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 members data every day by committing to work within our company ethics and policies

Additional Requirements

Flexibility to cross-train and perform pre-certification functions as determined by business need.

Non-standard work schedule including holidays and weekends as needed based on departmental staffing requirements.

Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook Word Excel PowerPoint) IM/video conferencing (Teams & Zoom) and telephones efficiently.

A high degree of personal accountability and trustworthiness a commitment to working within Quantum Healths policies values and ethics and to protecting the sensitive data entrusted to us.

#LI-HW1 #LI-Hybrid