Registered Nurse, Pre-Certification Review Pharmacy

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 Pre-Certification Review Nurse - Pharmacy is responsible for reviewing and processing coverage determinations and utilization management reviews for specialty medications, to include site of care assessments, for enrollees 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.  A successful individual will apply critical thinking to achieve proper clinical decisions when performing clinical reviews. The role requires use of multiple systems, acquisition of all relevant clinical documentation, and other clinical resources to achieve proper decisions in utilization management reviews.  

The Pre-Certification Review Nurse – Pharmacy will work and collaborate with a multi-disciplinary clinical team of Pharmacists and Medical Directors to provide a customer-centered experience within service level expectations.  Location: This position is located at our Dublin, OH campus or may work remotely anywhere in the United States of America.  

What you’ll do (Essential Responsibilities) 

Clinically review all requests for provider-administered specialty medications for appropriateness 

Support providers and members in optimization of site of care for requested services   

Demonstrate and expand a working knowledge of all clinical processes, medical policy as well as relevant employer benefit plans and how to access needed information.  

Work collaboratively with Medical Directors and Pharmacists for all relevant requests 

Serve as a Subject Matter Expert (SME) for infusible and injectable medication-related services 

Communicate with members, providers, facilities, and all internal work groups regarding outcome of requests.  

Identify of members who may be appropriate for care/case management services (Complex, High cost, Transplant)  

Identify care coordination opportunities and work with operational, clinical, and customer-facing teams on as needed basis.  

All other duties as assigned. 

What you’ll bring (Qualifications) 

Education: Bachelor’s degree in nursing or closely related field or equivalent experience 

Licensure and Credentialing: Must hold an active, unrestricted, and unencumbered professional license in good standing with the state board of licensure in one of the applicable clinical disciplines: Registered Nurse (RN) or other licensed healthcare professional authorized to conduct an assessment independently. Where applicable, clinicians must hold a Multi-State License (MSL) issued through the relevant licensure compact (e.g., Nurse Licensure Compact for RNs). For clinicians in states that do not offer MSL, or for disciplines for which an MSL program has not been launched, employees must be willing and able to obtain and maintain additional state licenses as required to support members served by the organization. Both the MSL and individual state licenses must be obtained within 90 days of hire. Maintenance of required licensure, including timely renewal and compliance with state board regulations, is a condition of employment. 

Experience: Minimum of 2 years of managed care and/or direct care nursing experience required. 

Ability to obtain additional licenses, as needed (with support from Quantum Health) 

Experience with Specialty Pharmacy/Pharmaceuticals required 

Experience with Utilization Management required 

Makes clinical decisions quickly and at times decides and acts with limited information 

Excellent critical thinking skills 

Strong interpersonal, verbal and written communication skills verbal and written communication skills 

Self-directed, organized with excellent time management skills 

Excellent computer skills including Microsoft applications 

Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently. 

A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us.