Quantum Health
  • - Clinical Services
  • Columbus, OH, USA
  • Salary
  • Full Time

Job Title: Utilization Review Nurse

Working Group: Clinical Operations

Reports to: Pod Manager

Location & Hours: This position is located at our office in Columbus,OH. Hours are Mon-Fri 9a-6p, 10a-7p, or 11a-8p

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. 

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:

  • 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

 

LAST UPDATED: 1/9/2018

Quantum Health
  • Apply Now

  • Follow Us On Social Media

  • Follow Our Jobs On Facebook Follow Our Jobs On Twitter
  • Share This Page

.