Utilization Review Nurse – RN or LPN
Job title: Utilization Review Nurse - RN or LPN
Company: Quantum Health
Job description: Description
Welcome Bonus: $2,500 for external candidates (rehires not eligible)
Location: All clinical positions are located on site at our Dublin, Ohio campus
We’re on a mission to make healthcare simpler and more effective. We fight to ensure our members get the care they need, when they need it, at the most affordable cost – that’s what makes us Healthcare Warriors™. If you’d like to join us, we’d love to talk to you – even if you don’t match every single requirement.
The Utilization Review Nurse (Registered Nurse, RN / Licensed Practical Nurse, LPN) reviews and processes medical service requests for members of Quantum Health’s employer groups in an inpatient setting. This Nurse acquires all clinical documentation in order to process the requests within the designated timeframes indicated. The Utilization Review (UR) Nurse also functions as a clinical resource to other Quantum Health associates in Precertification, Patient Services/Care Coordination, Personal Care Guide Nurses, Client Services and Sales.
- What you’ll do
- Assess and review all requests for inpatient medical services requiring clinical review against Quantum Health’s adopted clinical review criteria.
- Conduct initial clinical reviews, concurrent reviews and retrospective reviews.
- Utilize Quantum Health’s adopted clinical criteria during all aspects of the review process and document outcomes in authorization database.
- Facilitate discharge-planning process during daily concurrent review and post discharge, including arranging skilled nursing care, rehabilitation, home infusion and other outpatient ancillary services.
- Communicate with patients, providers, facilities and internal partners regarding outcomes.
- Coordinate integrated health management services for each patient and provide benefit and health information to patients, caregivers, providers and facilities so they can make informed health decisions.
- Provide 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.
- Research vague or questionable procedures and present findings to the Chief Medical/Physician Peer Reviewer for opinion; Provide timely notification of potential non-certifications.
- All other duties as assigned.
- What you’ll bring
- Education / Licensure: Active license in good standing as a Registered Nurse (RN) or Licensed Practical Nurse (LPN) in Ohio required.
- 2+ years of clinical experience with direct patient care in a hospital setting required.
- Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
- Experience in care management/coordination programs and services preferred.
- Excellent verbal and written communication skills. Comfortable communicating with members and providers via phone regularly throughout the day.
- Trustworthy and accountable behavior, capable of viewing and maintaining confidential personal information daily.
- Ability to communicate effectively with members and providers in implementing clinical services; Translate complex clinical concepts for non-clinical audiences.
- What’s in it for you
- Compensation: Competitive base pay, incentive plans and employee referral bonuses.
- Coverage: Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption assistance, EAP, TelaDoc services and more.
- Retirement: 401(k) plan with up to 4% employer match and full vesting on day one.
- Balance: Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
- Development: Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings and leadership development.
- Culture: Recognition as a Best Place to Work for 15+ years, dedication to
, and people-first values that drive every decision. * Environment: A modern workplace with a casual dress code, open floor plans, full-service dining, free snacks and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room, notary and dry-cleaning services and more! Check out our home:
- What you should know
- Internal Associates: Already a Healthcare Warrior? Apply internally through Jobvite.
- Process: Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check
- Diversity, Equity and Inclusion: Quantum Health welcomes everyone. We value our diverse team and suppliers, we’re committed to empowering our ERGs, and we’re proud to be an
- . * Agencies: Quantum Health does not accept unsolicited resumes or outreach from third-parties. Absent a signed MSA and request/approval from Talent Acquisition to submit candidates for a specific requisition, we will not approve payment to any third party.
- Sponsorship: Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.
- Actual compensation is based on a combination of experience and qualifications
#LI-HW1 #LI-Onsite
Expected salary:
Location: New Albany, OH
Job date: Sat, 18 Feb 2023 06:45:22 GMT
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