Behavioral Health UM Clinician en Quantum Health

Description

• Assess and review all requests for all behavioral health and substance use disorder inpatient and outpatient levels of care and transitions in relation requiring clinical review against plan language and the appropriate clinical criteria. Conduct initial clinical review, concurrent review, and retrospective review.
• Utilize critical thinking and clinical knowledge to make independent decisions and determinations, following Quantum Health workflows.
• Utilize Quantum Health adopted clinical criteria during all aspects of the review process and document outcomes in authorization database.
• Facilitate discharge planning process during concurrent review and post discharge. This includes making arrangements for Residential, PHP, IOP and other outpatient services.
• Communicate with patient, provider, facility, and internal work groups regarding outcome of requests. Promote the mission and core values of Quantum Health.
• Research status of vague or questionable procedures and present to the Chief Medical Officer/Physician Peer Reviewer for review. Notify Chief Medical Officer/Physician Peer Reviewer of all potential non-certifications within the appropriate time frames.
• Prepare and present high-quality medical reviews for MD collaboration and determination.
• Facilitate communication between medical provider including external review agencies.
• Negotiate for services needed if no clear benefit exists or if the services can only be provided out of network.
• Coordinate health management services in an effort to provide integrated health services for each patient and provide benefit and health information to patients, caregivers, providers and facilities so they are able to make informed health decisions.
• Re-direction of out of network service requests to in network whenever possible to ensure members obtain the optimum benefit.
• Identify potential cases for high risk/high cost and refer to the appropriate case management team. Maintain contact with internal clinical staff for transfer of cases for medical management when appropriate.
• Maintain a working knowledge of all Quantum Health workflows.
• Be a clinical resource for all Quantum Health work groups. 
• Provide monitoring and oversight of non-clinical staff activities and be available to non-clinical staff during Quantum Health’s business hours.
• Other duties as assigned

• Licensure/Certifications: Registered nurse with active license in Ohio or Licensed Social Worker with active license in Ohio
• Minimum of 4 years’ experience in a Behavioral Health setting
• Experience in health management preferred
• Ability to make decisions that are timely and that achieve results consistent with business goals and organizational culture
• Driven to work independently with limited need for daily supervision
• Possess excellent verbal and written communication skills
• Strong ability to communicate effectively with patients, physician practices, hospital facilities
• Aptitude to research and identify issues using critical thinking
• Perform as a team member with the working group, interact professionally with other entities both internally and externally
• Proactively present issues and ask questions
• Outstanding computer skills, navigating multiple systems, and Microsoft applications
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
• Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently. 
• 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-Hybrid

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.

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.