Pre-Certification Nurse RN

at Quantum Health

Columbus, OH

Posted on Sep. 12, 2017

Full Time

Health Insurance, Dental Insurance, Vision Insurance, 401k / Retirement Plan

Quantum Health is a fast growing company delivering better healthcare while lowering healthcare costs. If you are passionate about helping people and want to launch a career at one of the Best Places to Work in Columbus and the USA, now is your time to join our winning culture! We are looking for a Pre-Certification Nurse.

Must Apply in Person
Wednesday, September 27th / 10am – 2pm
Click apply for location details and to register your interest.

Education requirementsLicensed as a Registered Nurse with an unrestricted license

Experience requirementsMinimum of five years clinical experience
Experience in health management

QualificationsStrong ability to communicate effectively with patients, employer groups, and physicians
Effective problem solving skills
Computer literacy
Possess excellent time management skills

ResponsibilitiesRoles and Tasks:

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
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, care givers, providers and facilities to enable informed health decisions
Clinical review of all requests for health services or treatment that require assessment against clinical criteria
Research status of vague or questionable procedures and present to the Medical Director 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
Prepare letters explaining non-covered requests
Document interventions in the database
Direct out of network requests to in network providers to ensure members secure the optimum desired benefits and negotiate fee arrangements with out of network providers, as needed
Facilitate the discharge planning process during pre-service review and coordinate with other clinical work teams
Notify Medical Director 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 CHC business hours
Maintain a working knowledge of all CHC workflows

Work hoursThe shifts available are 9a-6p, 10a-7p, and 11a-8p

Save job

Quick Apply

Choose One: Paste
Click to try another word
Save your application info for next time?
Yes, please! I agree to the Terms of Service.
Other Apply Options