RN, Pre-Certification Review - Pharmacy

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

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 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 Health’s 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.

What you’ll 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 you’ll bring

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.

Bachelor’s degree in nursing or closely related field or equivalent 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 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.

#LI-HW #LI-Hybrid