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

Job Title: Pre-Certification 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 precertification nurse is responsible for reviewing and processing medical services requests for members 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. The precertification nurse also functions as a clinical resource to other staff in the company such as Utilization Review, 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 medical services requiring clinical review against Quantum Health adopted clinical review criteria
  • Communicate with patient, provider, facility, and internal work groups regarding outcome of requests
  • Act as 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, caregivers, providers and facilities to enable informed health decisions
  • Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review
  • Identify potential high risk/high cost cases and chronic condition cases and refer to the appropriate case management team
  • Identify care coordination opportunities for patients being admitted for elective surgical procedures
  • Document interventions in the database
  • Direct out of network requests to in network providers to ensure members secure the optimum desired benefits
  • Facilitate the discharge planning process during pre-service review and coordinate with other clinical work teams
  • Notify Chief Medical Officer/Physician Peer Reviewer of all requests you are unable to certify within specified time frames
  • Provide monitoring and oversight of non-clinical staff activities and be available to non-clinical staff during Quantum Health's business hours
  • Maintain a working knowledge of all Quantum Health's 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
  • Minimum of two years clinical experience with direct patient care required
  • Experience in health management preferred
  • Strong ability to communicate effectively with patients, employer groups, and physicians
  • Possess excellent critical thinking skills
  • Outstanding computer skills including Microsoft applications
  • Possess excellent time management skills
  • Ability to make decisions that are timely and achieve results consistent with business goals and organizational culture

 

LAST UPDATED: 1/9/2018

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