Utilization Review Nurse

$51,800 - $102,800 a year

Who We Are

Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re 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 – that’s why we call ourselves Healthcare Warriors®.

We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement.

About the Role

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.

• Location: This position is located at our Dublin, OH campus.
• What you’ll 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 Health’s business hours.
• All other duties as assigned.
• What you’ll bring (Qualifications)

Licensure and Credentialing: Must hold an active, unrestricted, and unencumbered professional license in good standing with the state board of licensure in one of the applicable clinical disciplines: Registered Nurse (RN), Licensed Practical Nurses (LPNs) currently employed by Quantum Health, or other licensed healthcare professional authorized to conduct an assessment independently. Where applicable, clinicians must hold a Multi-State License

(MSL) issued through the relevant licensure compact (e. g., Nurse Licensure Compact for RNs).

For clinicians in states that do not offer MSL, or for disciplines for which an MSL program has not been launched, employees must be willing and able to obtain and maintain additional state licenses as required to support members served by the organization.

Both the MSL and individual state licenses must be obtained within 90 days of hire. Maintenance of required licensure, including timely renewal and compliance with state board regulations, is a condition of employment.

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 member’s 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 Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us. Who we are

Identify potential cases for high risk/high cost/chronic condition and refer to the appropriate case