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RN, Registered Nurse- Pre-Certification Pharmacy Review (Utilization Management Pharmacy experience required)
Quantum Health is seeking a remote Registered Nurse for a Pre-Certification Pharmacy Review role focused on utilization management and specialty medications. The position involves reviewing coverage determinations and collaborating with a multidisciplinary clinical team.
Job Description
About the Role
The Pre-Certification Review Nurse - Pharmacy is responsible for reviewing and processing coverage determinations and utilization management reviews for specialty medications, including site of care assessments.
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.
- 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 internal work groups regarding outcomes.
- Identify members appropriate for care and case management services.
Qualifications
- Bachelor's degree in nursing or closely related field (or equivalent experience).
- Active, unrestricted Registered Nurse (RN) license in the state of Ohio.
- Minimum of 2 years of managed care and/or direct care nursing experience.
- Experience with Specialty Pharmacy/Pharmaceuticals and Utilization Management required.
Requirements & Skills
Specialty
Pharmacy Review
Education
Bachelor
Experience
2+ years
Licenses
RN
Skills
Utilization ManagementSpecialty PharmacyPre-CertificationCare CoordinationCase ManagementClinical Documentation