Company name
Quantum Health LLC.
Location
Dublin, OH, United States
Employment Type
Full-Time
Industry
Healthcare, Nursing
Posted on
Apr 29, 2023
Profile
Description
Welcome Bonus:
$2,500 for external candidates
(does not apply to rehires)
Location:
All clinical positions are
located
on site at our Dublin, Ohio campus
We’re
on a mission to make healthcare simpler and more effective. We fight to ensure our members get the care they need, when they need it, at the most affordable cost –
that’s
what makes us Healthcare Warriors™. If
you’d
like to join us,
we’d
love to talk to you – even if you
don’t
match
every single requirement.
The
Registered Nurse (RN) – Appeals
is responsible for
managing all clinical appeal requests according to Quantum Health’s defined process for the receipt, logging, preparing for review,
evaluation
and response. This critical clinical subject matter expert works to increase the consistency,
efficiency
and appropriateness of responses for all appeal service requests.
What
you’ll
do
Review and process all appeal requests; Prepare requests for review by researching Specific Plan Detail (SPD) provisions, applicable criteria, analyzing the basis for appeal and preparing a written summary of each case.
Assure
timely
processing and response to appeal requests.
Communicate with
member
provider
facility
, and all internal work groups
regarding
appeal requests/outcomes.
Collaborate with Medical Directors, Physician reviewers, External Medical Directors, and Independent Review Organization (IRO) to process all requests requiring physician review.
Identify
care coordination and case management opportunities.
Maintain a working knowledge of all clinical processes and workflows, employer benefit plans and related documentation.
Participate in educational training with clinical staff
regarding
the appeal process; Partner with the clinical operations managers to
identify
coaching opportunities for the clinical services team,
identify
trends, and improve processes.
Assist
pre-certification team as needed with medical reviews,
assist
with pre-certification training, serve as enhanced pre-certification trainer for new nurses,
provide
coaching to care coordination nurses on appeal cases, etc.
All other duties as assigned.
What
you’ll
need
Licensure: Active license in good standing as a Registered Nurse (RN
in the State of Ohio required
Education: Bachelor of Science in Nursing (BSN) degree in nursing preferred
3 years of clinical experience with direct patient care in a hospital setting
required
Experience working in the clinical review and/or appeal process, ideally in a health insurance setting preferred.
Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
Excellent verbal and written communication skills. Comfortable communicating with members
and providers via phone regularly throughout the day.
Trustworthy and accountable behavior, capable of viewing and
maintaining
confidential personal information daily
Ability to communicate effectively with members and providers in implementing clinical services; Translate complex clinical concepts for non-clinical audiences.
What’s
in it for you
Compensation:
Competitive base pay, incentive plans and employee referral bonuses.
Coverage:
Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption
assistance
, EAP, Teladoc services and more.
Retirement:
401(k) plan with up to 4% employer match and full vesting on day one.
Balance:
Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
Development:
Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid
trainings
and leadership development.
Culture:
Recognition as
a Best
Place to Work for 15 years, dedication to
diversity, philanthropy and sustainability
, and people-first values that drive every decision.
Environment:
A modern workplace with a casual dress code, open floor plans, full-service dining, free
snacks
and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room,
notary
and dry-cleaning services and more! Check out our home:
https://youtu.be/xRnbvCW_YgA
What you should know
Internal Associates:
Already a Healthcare Warrior? Apply internally through Jobvite.
Process:
Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check
Diversity,
Equity
and Inclusion:
Quantum Health welcomes everyone. We value our diverse team and suppliers,
we’re
committed to empowering our ERGs, and
we’re
proud to be an
equal opportunity employer
Agencies:
Quantum Health does not accept unsolicited resumes or outreach from
third-parties
. Absent a signed MSA and request/approval from Talent Acquisition to
submit
candidates for a specific requisition, we will not approve payment to any third party.
Sponsorship:
Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.
*Actual compensation is based on a combination of experience and qualifications
#LI-HW1 #LI-Onsite
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Company info
Quantum Health LLC.
Website : http://quantum-health.com