Remote Cvs Utilization Management Nurse Jobs in Ohio

Description

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

At Quantum Health, the leader in healthcare navigation, we are privileged and humbled to serve an amazing group of clients and members. As our relationships flourish and our business expands, we find ourselves in the fortunate position of adding a Medical Director to our incredible team. This physician will possess relevant experience within the virtual healthcare space. This experience may be with a traditional/non-traditional carrier or another administrative healthcare service provider. In addition, they will possess the unique combination of strong analytical skills, collaboration, responsiveness, diligence and a passion for both written and verbal communications.

In this role, the successful candidate will support the award-winning culture, Columbus Best Places to Work, as a hands-on, roll-up-your-sleeves, solutions-oriented medical professional. This is not a lofty, theoretical role. The ideal candidate will find themselves highly engaged focusing their attention on the front line while partnering with our clinical team to drive the best possible outcomes for every member.

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

What you’ll do (Essential Responsibilities)

• Serves as a key clinical resource for staff. Establishes criteria and protocols for standard medical treatment inquiries and renders determinations on requests for healthcare services and/or treatment.
• Conducts daily review of individual cases and has necessary case level conversations as requested. This includes prior authorizations and denial decisions for cases that do not meet established evidence-based criteria
• Provides clear and concise documented medical review determinations and support on requested reviews within the established time frames
• Provides clinical and nurse consultations
• Identifies opportunities to implement best practices approaches and introduce innovations to provide improved outcomes
• Performs utilization review and case management support on complex members
• Provides support over the phone, through messaging and video to support chronic disease management
• Offers peer-to-peer discussions regarding determinations as necessary
• Serves as a medical liaison to physicians, hospitals and insurance carriers
• Provides determination on appeals for cases where they did not make the initial determination
• Utilizes data resources and tools that helps our team provide personalized care to our clients
• Evaluates and interprets data. Identifies areas for improvement with a focus on interventions to improve client outcomes
• All other duties as assigned.

What you’ll bring (Qualifications)

• Education: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• License/Certification: Board certification in primary specialty required.
• Experience: Minimum of five (5) years of progressively responsible clinical practice experience.
• Minimum of two (2) years of physician clinical review experience, preferably within a commercial health plan or utilization management environment.
• Strong written and verbal communication skills, including clear clinical documentation.
• Collaborative, team-oriented mindset with the ability to work effectively across disciplines.
• Knowledge of the U.S. healthcare delivery system.
• Demonstrated knowledge of utilization management principles and evidence-based criteria (e.g., InterQual).
• Commitment to protecting company and member data by adhering to organizational ethics, privacy, and security policies.
• Protect and take care of our company and member’s data every day by committing to work within our company ethics and policies
• Licensure, Qualifications, and Clinical Peer Review Requirements
• Hold a current, valid, and unrestricted license to practice medicine that is recognized in the relevant jurisdiction(s); ability to obtain and maintain multistate licensure as required.
• Maintain licensure of a type and scope that permits the application of independent clinical judgment to evaluate member needs and render utilization review determinations.
• Any license restriction permitted by a jurisdiction must be reviewed and approved by the organization and must not impair the ability to perform Medical Director or clinical peer review responsibilities.
• Be knowledgeable of the clinical issues under review, including applicable medical or behavioral health conditions, procedures, treatments, and services.
• Demonstrate familiarity with current, evidence-based clinical guidelines, standards of care, and relevant emerging or novel treatments.
• Be qualified to render clinical opinions and utilization review determinations, as determined by organizational leadership, and perform reviews within the scope of licensure and professional practice.
• Function under and provide oversight consistent with Medical Director responsibilities for utilization management activities.
• 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.

#LI-HW1 #LI-Remote

What’s in it for you

• Compensation: Competitive base and incentive compensation
• 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!

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 .
• Tobacco-Free Campus: To further enable the health and wellbeing of our associates and community, Quantum Health maintains a tobacco-free environment. The use of all types of tobacco products is prohibited in all company facilities and on all company grounds.
• Compensation Ranges: Compensation details published by job boards are estimates and not verified by Quantum Health. Details surrounding compensation will be disclosed throughout the interview process. Compensation offered is based on the candidate’s unique combination of experience and qualifications related to the position.
• Sponsorship: Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.
• 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.

Reasonable Accommodation: Should you require reasonable accommodation(s) to participate in the application/interview/selection process, or in order to complete the essential duties of the position upon acceptance of a job offer, click here to submit a recruitment accommodation request.

California Employee and Job Applicant Notice of Collection of Personal Information: If you are a California resident, Quantum Health may collect personal information in connection with your application for employment and, if hired, during the course of your employment. The categories of personal information collected and the purposes for which that information is used are described in our California Employee and Job Applicant Notice of Collection of Personal Information. Please review the notice here:
California Employee and Job Applicant Notice

Recruiting Scams: Unfortunately, scams targeting job seekers are common. To protect our candidates, we want to remind you that authorized representatives of Quantum Health will only contact you from an email address ending in @quantum-health.com. Quantum Health will never ask for personally identifiable information such as Date of Birth (DOB), Social Security Number (SSN), banking/direct/tax details, etc. via email or any other non-secure system, nor will we instruct you to make any purchases related to your employment. If you believe you’ve encountered a recruiting scam, report it to the Federal Trade Commission and your state’s Attorney General.