RN, Registered Nurse - Pre-Certification

About the role

The Pre-Certification Nurse is responsible for all aspects of the prior authorization process for members of Quantum Health’s employer groups. This includes assessing and reviewing all requests for medical services requiring clinical review, communicating with patients, providers, facilities, and internal work groups, coordinating health management services, providing benefit and health information, facilitating the discharge planning process, and promoting the mission and core values of Quantum Health.

Responsibilities

• Assess and review all requests for medical services requiring clinical review against Quantum Health adopted clinical review criteria.
• Communicate with patient, provider, facility, and internal work groups regarding outcome of requests.
• Cook up integrated health services for each patient and provide benefit and health information to patients, caregivers, providers and facilities to enable informed health decisions.
• Identify care coordination opportunities for patients admitted for elective surgical procedures.
• Communicate and work effectively with colleagues and other teams within the organization.
• Utilize subject matter expertise, critical thinking, and clinical knowledge to render independent decisions and determinations, following Quantum Health workflows.
• Direct out of network requests to in-network providers to ensure members secure the optimum desired benefits.
• Facilitate the discharge planning process during pre-service review and coordinate with other clinical work teams.
• Promote the mission and core values of Quantum Health by proactively managing client/member expectations as it related to the pre-certification process.
• Act as clinical resource for all Quantum health work groups.
• Maintain a working knowledge of all Quantum Health’s workflows.
• Provide monitoring and oversight of non-clinical staff activities and be available to non-clinical staff during Quantum Health’s business hours.
• Identify potential high risk/high-cost cases and chronic condition cases and refer to the appropriate case management team.
• Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review.
• Prepare and present high-quality medical reviews for MD collaboration and determination.
• Facilitate communication between medical providers including external review agencies.
• Notify Chief Medical Officer/Physician Peer Reviewer of all requests you are unable to certify within specified time frames.

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.
• Experience: Minimum of two years clinical experience with direct patient care required in a hospital setting. Experience in health management preferred.
• Strong ability to communicate effectively with patients, employer groups, and physicians.
• Driven to work independently with limited need for daily supervision.
• Aptitude to research and identify issues using critical thinking.
• Outstanding computer skills including Microsoft applications.
• Possess excellent time management skills.
• Ability to make decisions that are timely and achieve results consistent with business goals and organizational culture.
• 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.