Inpatient Utilization Review Nurse - Care & Discharge Champion

Quantum Health, Inc.; Dublin (OH); On-site; USD 52,000 - 103,000; Full time

Job summary

Quantum Health, Inc. is seeking a Utilization Review Nurse to review and process inpatient services for employer-group members in Dublin, OH. This role entails assessing requests, applying plan language criteria, and coordinating with providers to ensure timely, high-quality care and discharge planning.

The nurse collaborates with medical staff, demonstrates clinical expertise, and supports cost-effective, medically necessary care while maintaining confidentiality and compliance with policies.

Qualifications

• Active, unrestricted clinical license in an applicable discipline.
• Minimum 2 years of inpatient clinical experience.
• Health management experience is preferred.
• Ability to make timely decisions aligned with goals.
• Works independently with strong communication.
• Proficient with Microsoft Office and teleconferencing tools.
• Commitment to data privacy and company ethics.

Responsibilities

• Assess and review inpatient requests against plan language and criteria.
• Conduct initial, concurrent, and retrospective clinical reviews.
• Use clinical criteria and document outcomes in authorization systems.
• Support discharge planning and coordinate post-acute services.
• Communicate with patients, providers, facilities, and teams.
• Refer questionable cases to Chief Medical Officer for review.
• Prepare high-quality medical reviews for MD collaboration.
• Coordinate with external review agencies as needed.
• Coordinate health management services to inform patient decisions.
• Redirect out-of-network requests to in-network.
• Identify high-risk or high-cost cases and involve case management.
• Maintain knowledge of Quantum Health workflows.
• Be a clinical resource for teams.
• Monitor non-clinical staff activities during business hours.
• Perform other duties as assigned.

Skills

RN licensure

Clinical experience

Inpatient care

Critical thinking

Communication skills

MS Office

Tools

MSL

Job description

Quantum Health, Inc. is seeking a Utilization Review Nurse to review and process inpatient services for employer-group members in Dublin, OH. This role entails assessing requests, applying plan language criteria, and coordinating with providers to ensure timely, high-quality care and discharge planning.

The nurse collaborates with medical staff, demonstrates clinical expertise, and supports cost-effective, medically necessary care while maintaining confidentiality and compliance with policies.