Pre-Cert Pharmacy Review Nurse, RN (PBM- Pharmacy experience required)

Description

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. Location: This position is located at our Dublin, OH campus or may work remotely anywhere in the United States of America.

What you’ll do (Essential Responsibilities)

Clinically review all requests for provider-administered specialty medications for appropriateness

Support providers and members in optimization of site of care for requested services

Demonstrate and expand a working knowledge of all clinical processes, medical policy as well as relevant employer benefit plans and how to access needed information.

Work collaboratively with Medical Directors and Pharmacists for all relevant requests

Serve as a Subject Matter Expert (SME) for infusible and injectable medication-related services

Communicate with members, providers, facilities, and all internal work groups regarding outcome of requests.

Identify of members who may be appropriate for care/case management services (Complex, High cost, Transplant)

Identify care coordination opportunities and work with operational, clinical, and customer-facing teams on as needed basis.

All other duties as assigned.

What you’ll bring (Qualifications)

Education: Bachelor’s degree in nursing or closely related field or equivalent experience

Licensure/Credentials: Current and active and unrestricted license as a Registered Nurse (RN) in the state of Ohio.

Experience: Minimum of 2 years of managed care and/or direct care nursing experience required.

Ability to obtain additional licenses, as needed (with support from Quantum Health)

Experience with Specialty Pharmacy/Pharmaceuticals required

Experience with Utilization Management required

Makes clinical decisions quickly and at times decides and acts with limited information

Excellent critical thinking skills

Strong interpersonal, verbal and written communication skills verbal and written communication skills

Self-directed, organized with excellent time management skills

Excellent computer skills including Microsoft applications

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.

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