[Hiring] Pre-Certification Review Nurse - Pharmacy @Quantum Health

Role Description

Your clinical expertise can make a real difference in helping members access the right specialty medications and care. As a Pre-Certification Review Nurse - Pharmacy, you’ll:

• Review coverage determinations and utilization management requests for provider-administered specialty medications, including site-of-care assessments.
• Use your clinical judgment, specialty pharmacy knowledge, and critical-thinking skills to review documentation, apply medical policies and benefit requirements, and make timely, well-supported clinical decisions.
• Collaborate closely with Pharmacists, Medical Directors, providers, facilities, and other clinical teams to create a member-centered experience while meeting utilization management and service-level expectations.

Qualifications

• A bachelor’s degree in Nursing or a closely related field, or equivalent experience.
• An active, unrestricted, and unencumbered RN license, or another applicable professional healthcare license that authorizes independent clinical assessment.
• Where applicable, an active Multi-State License through the Nurse Licensure Compact, or the ability to obtain and maintain required additional state licenses within 90 days of hire.
• At least 2 years of managed-care and/or direct-care nursing experience.
• Specialty pharmacy/pharmaceutical experience, including experience working with specialty medications.
• Utilization Management experience and the ability to make timely clinical decisions using available information.
• Strong critical-thinking, organization, communication, and time-management skills.
• Comfort working across multiple systems and using Microsoft Outlook, Word, Excel, PowerPoint, Teams, Zoom, and similar tools.
• A high degree of accountability, discretion, and commitment to protecting sensitive member and healthcare information.

Requirements

• Quantum Health will support associates in obtaining additional required licenses as needed.

Benefits

• Compensation: Competitive base pay, incentive plans, and employee referral bonuses.
• Coverage: Health, vision, and dental, plus life insurance, legal and identity protection, adoption assistance, EAP resources, TelaDoc services, and more.
• Retirement: 401(k) with up to a 4% employer match and full vesting from day one.
• Balance: PTO, seven paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
• Development: Up to $5,250 annually in tuition reimbursement, certification and continuing education support, paid training, and leadership development.
• Culture: A people-first environment focused on collaboration, inclusion, community, and making a meaningful difference in healthcare.