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

Roles and Duties:

  • Promote the mission and core values of Quantum Health
  • Assess all the 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
  • 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 decision.
  • Tasks:
  • Assess each request against adopted clinical review criteria
  • Conduct pre-review screening, initial clinical review, concurrent review, and retrospective review
  • Facilitate in discharge planning process pre-service, during concurrent review, and post discharge, this includes but is not limited to: making arrangements for skilled nursing care, rehabilitation, home infusion and other out patient 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 requests to in network requests whenever possible to ensure members obtain the optimum benefit
  • Negotiate fee arrangements with out of network providers on a case by case basis
  • Facilitate communication between medical provider including external review agencies
  • Notify Medical Director 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 CHC business hours
  • Responsible for the reporting process which encompasses varied workflows depending upon employer groups
  • Responsible for review of diagnoses making appropriate referrals to CM/DM when appropriate
  • Maintain a working knowledge of all CHC workflows
  • Documentation of all personal interventions in Pivot
  • Other duties as assigned by the Director of Clinical Services

Skills:

  • Licensed as a Registered Nurse
  • Minimum of five years clinical experience
  • Experience in health management desired
  • Strong ability to communicate effectively with patients and physician practices in implementing clinical services program functions
  • Ability to make decisions that are timely and well thought out that achieve results consistent with business goals and organizational culture
  • Ability to work independently and self-directed with limited need for day to day supervision
  • Possess excellent time management skills
  • Computer literacy
  • Strong customer service skills
  • Possess excellent verbal and written communication skills

 




This position has been closed and is no longer available.
Quantum Health

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