Review Nurse-PA/UM

Alliant Health Solutions, Inc.•Atlanta, GA

3d•Hybrid

About The Position

Alliant Health Solutions is recruiting a Hybrid Review Nurse for its Prior Authorization and Utilization Management (PA/UM) team. The position conducts prior approval and precertification reviews for Georgia Fee-for-Service Medicaid members across the team’s defined review types while meeting and exceeding contract expectations. The Review Nurse evaluates clinical information, approves cases that meet applicable criteria, documents review decisions, and refers cases that cannot be approved to a Referral Nurse Coordinator for peer review. The role also involves consultation with PA/UM leadership or Medical Directors, participation in quality improvement and peer review, protection of confidential information, and collaboration with team members on projects and process improvement. Travel to company locations, customer meetings, or other locations may be required as needed.

Requirements

Registered Nurse with at least three years of recent clinical experience.
Current and unencumbered Georgia nursing license.
Knowledge of clinical theory and problem-solving skills.
Strong organizational skills and ability to demonstrate work priorities.
Excellent interpersonal, written, and verbal communication skills.
Ability to work with considerable independence, using creative thinking, thorough analysis, and innovative approaches to problem resolution.
Computer literacy and experience with MS Windows products.
Ability to type 30–50 words per minute.
Ability to travel by car or plane to company locations, customer meetings, or other locations as needed.

Nice To Haves

Knowledge of ICD-10-CM, CPT codes, and InterQual criteria.
Utilization Review or Prior Approval Precertification experience.

Responsibilities

Perform provider prior approval and precertification reviews according to PA/UM policies and procedures.
Evaluate initial clinical information and approve cases that meet criteria; clearly document the rationale for review decisions using appropriate criteria or nursing judgment.
Refer cases that cannot be approved using InterQual criteria or nursing judgment to a Referral Nurse Coordinator for peer review.
Consult with the Manager, Supervisor PA/UM, or Medical Directors regarding peer consultant review decisions or cases requiring physician clarification.
Participate in quality improvement and peer review activities.
Maintain confidentiality and security of review information and medical records in accordance with HIPAA, URAC regulations, company policies, and Alliant policy.
Collaborate with team members to support new projects and continuous improvement of team work processes.
Promote teamwork, professionalism, effective communication, and positive behaviors.
Demonstrate compliance with corporate and departmental policies, including attendance, punctuality, and dress expectations.
Perform other duties as assigned.
Travel by car or plane to company locations, customer meetings, or other locations as needed.