Registered Nurse, Transplant Utilization Review New

Location: This position is located at our Dublin, OH campus. 

Multistate Licensure: Quantum Health nurses must be willing and able to obtain and maintain nursing licensure in multiple states, as required by the business. All application and filing fees will be paid by Quantum Health.  

Who we are

Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.

We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement.  

About the role

The Registered Nurse (RN) - Transplant Utilization Review is responsible for reviewing and processing medical service requests for members of Quantum Health’s employer groups in an inpatient setting across the transplant continuum. 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 on the team and within the company such as Clinical Support Coordinators, Precertification, Patient Services, Personal Care Guide nurses, and Client Engagement Services. 

What you’ll do

• Assess and review all requests for inpatient transplant related services, requiring clinical review against Quantum Health’s adopted clinical review criteria. 
• Conduct initial clinical review, concurrent review, and retrospective review. 
• Utilize Quantum Health adopted clinical criteria during all aspects of the review process and document outcomes in authorization database. 
• Maintain a working knowledge of all benefit plans and know where to access the needed information.
• Facilitate discharge planning process during daily concurrent review and post discharge. This includes arranging for skilled nursing care, rehabilitation, home infusion and other outpatient ancillary services. 
• Communicate with patient, provider, facility, and internal work groups regarding outcome of requests, including sending of transplant notifications and/or inpatient transplant admission notifications when applicable.
• Engage with member and providers via inbound calls through the transplant phone queue; Document Interventions in the database.
• Re-direction of non-COE or out of network service requests to COE or in network whenever possible to ensure members obtain the optimum benefit.
• Coordinate health management services to provide integrated health services for each patient and provide benefit and health information to patients, caregivers, providers, and facilities so they are able to make informed health decisions. 
• Identify potential cases for high risk/high cost/chronic condition and refer to the appropriate case management team.
• Notify Chief Medical Officer/Physician Peer Reviewer of all potential non-certifications within the appropriate time frames. 
• Facilitate communication between medical provider including external review agencies. 
• Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review. 
• All other duties as assigned.
  

What you’ll bring

• Licensure: Active license in good standing as a Registered Nurse (RN) in Ohio required. 
• Education: Bachelor of Science in Nursing (BSN) preferred. 
• Experience: 2+ years of clinical experience with direct patient care required; Proven clinical experience with organ and/or bone marrow transplants, preferred. 
• Excellent verbal and written communication skills. Comfortable communicating with members and providers via phone regularly throughout the day. 
• Ability to communicate effectively with members and providers in implementing clinical services; Translate complex clinical concepts for non-clinical audiences.  
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently. 
• Trustworthy and accountable behavior, capable of viewing and maintaining confidential information daily.