Welcome Bonus: $2,500 for external candidates
Location: This position is located at our Dublin, OH campus with hybrid flexibility
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.
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 why we call ourselves Healthcare Warriors®. We’re committed to building diverse and inclusive teams, so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every 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
What you’ll need
- 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.
- 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!
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.
- 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.
Note: Compensation information 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.
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 at ReportFraud.ftc.gov and your state’s Attorney General at https://www.usa.gov/state-attorney-general.