Registered Nurse, Pre-Certification Review Pharmacy

Founded in 1999 and headquartered in Central Ohio, Quantum Health is an independent healthcare navigation organization with one simple belief: no one should have to navigate the cost and complexity of healthcare alone.

Our Healthcare Warriors® help millions of members get the care they need, when they need it, while making healthcare simpler, more effective, and more affordable.

We’re more than 2,000 people and growing. If this opportunity excites you, we encourage you to apply even if your experience doesn’t match every qualification perfectly.

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.

You’ll 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.

You’ll also 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.

This position can work from our Dublin, Ohio campus or remotely anywhere in the United States.

• Use your clinical expertise. Review requests for provider-administered specialty medications and evaluate clinical appropriateness within established guidelines.
• Help members get care in the right setting. Support providers and members in evaluating and optimizing site-of-care options.
• Navigate the details. Review clinical documentation, medical policies, benefit plans, and other resources needed to make accurate and timely utilization management decisions.
• Collaborate on complex cases. Work closely with Pharmacists and Medical Directors to evaluate requests and determine appropriate next steps.
• Be a specialty medication resource. Serve as a subject matter expert for injectable and infusible medications and related services.
• Communicate with care. Clearly communicate request outcomes and next steps to members, providers, facilities, and internal partners.
• See the bigger picture. Identify members who may benefit from complex care, high-cost care, transplant, case management, or additional clinical support.
• Connect care across teams. Identify care coordination opportunities and partner with clinical, operational, and member-facing teams to help make them happen.

You’re a clinically confident nurse who enjoys applying your expertise in a different way. You’re comfortable reviewing complex information, making thoughtful decisions, and collaborating with other healthcare professionals to support the best possible outcome.

You bring:

• 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,…