Utilization Review Nurse (Fall 2018)

Quantum Health - Columbus, OH (30+ days ago)3.2


Job Title: Utilization Review Nurse

Working Group: Clinical Operations

Reports to: Pod Manager

Description: 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. The nurse is responsible for acquiring all clinical documentation to appropriately process the service request within the designated time frames indicated. The utilization review nurse also functions as a clinical resource to other staff in the company such as Precertification, Patient Services, Personal Care Guide nurses, Client Services, and Sales.

Location & Hours: This position is onsite at our office in Columbus, OH. Available shifts are 9a-6p, 10a-7p, and 11a-8p

Role and Tasks:
Promote the mission and core values of Quantum Health
Assess and review all requests for inpatient medical services requiring clinical review against Quantum Health's adopted clinical review criteria
Communicate with patient, provider, facility, and internal work groups regarding outcome of requests
Be a clinical resource for all Quantum Health work groups
Coordinate health management services in an effort to provide integrated health services for each patient and provide benefit and health information to patients, care givers, providers and facilities so they are able to make informed health decisions
Conduct initial clinical review, concurrent review, and retrospective review
Facilitate discharge planning process during daily concurrent review and post discharge. This includes making arrangements for skilled nursing care, rehabilitation, home infusion and other outpatient ancillary services
Utilize Quantum Health adopted clinical criteria during all aspects of the review process and document outcomes in authorization database
Re-direction of out of network service requests to in network whenever possible to ensure members obtain the optimum benefit
Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review
Identify potential cases for high risk/high cost/chronic condition and refer to the appropriate case management team
Document Interventions in the database
Facilitate communication between medical provider including external review agencies
Notify Chief Medical Officer/Physician Peer Reviewer of all potential non-certifications within the appropriate time frames
Provide monitoring and over-site of non-clinical staff activities and be available to non-clinical staff during Quantum Health's business hours
Responsible for review of diagnoses making appropriate referrals to Case Management when appropriate
Maintain a working knowledge of all Quantum Health workflows

Skills and Qualifications:
This position requires that employees successfully PASS 2 TESTS during 6-7 weeks of on the job training. The first test is at the midpoint of training, for continued employment. The second test is at the completion of training, for continued employment. Training will be Monday – Friday from 9:00 AM – 6:00 PM.
Unrestricted, active license as a Registered Nurse/Licensed Practical Nurse in the state of Ohio
Minimum of 2 years clinical experience with direct patient care required
Experience in health management preferred
Possess excellent critical thinking skills
Outstanding computer skills including Microsoft applications
Strong ability to communicate effectively with patients, physician practices, hospital facilities
Ability to make decisions that are timely and that achieve results consistent with business goals and organizational culture
Ability to work independently
Possess excellent time management skills
Possess excellent verbal and written communication skills
Join our Quantum culture, which rewards hard work while having fun! Benefits include:

3 weeks paid vacation
Medical/Dental/Vision insurance including domestic partner benefits
401(k) with a company match up to 4%
On-site amenities include a fitness facility, ping pong table, and serenity room with massage chairs
Education reimbursement
Free beverages, snacks, and ALWAYS fresh-popped popcorn
Want to join our winning culture? Then apply today at http:www.quantum-health.com/careers

Quantum Health is an Equal Opportunity Employer

LAST UPDATED: 1/9/2018