Review Nurse-PA/UM

Alliant Health Solutions, Inc.•Atlanta, GA

1d•Hybrid

About The Position

Alliant Health Solutions is recruiting a Hybrid Review Nurse for its Prior Authorization and Utilization Management (PA/UM) team. The Review Nurse conducts prior approval and precertification reviews for Georgia Fee-for-Service Medicaid members for the team’s defined review types while meeting and exceeding contract expectations.

Requirements

Registered Nurse, with at least three years of recent clinical experience required
Current and unencunbered Georgia nursing license required
Knowledge of clinical theory and problem-solving skills
Strong organizational skills with ability to demonstrate the work priorities
Excellent interpersonal, written, and verbal skills required
Knowledge, skill and ability to perform work with considerable independence by use of creative thinking, thorough analysis of problems, and use of innovative approaches to problem resolution
Computer literate, 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 preferred
Utilization Review or Prior Approval Precertification experience

Responsibilities

Perform reviews of provider prior approval/precertification requests as per PAUM policy and procedures
Evaluate initial clinical information and approve cases that meet criteria. Document clearly the rationale for all review decisions using appropriate criteria or nursing judgment
Refer cases that do not meet criteria and cannot be approved by InterQual criteria or nursing judgment to a Referral Nurse Coordinator who in turn assures review by a Peer Review Consultant on any case which a nurse cannot approve
Consult with the Manager, Supervisor PA/UM, or Medical Directors on issues related to Peer Consultant review decisions or cases requiring physician clarification
Participate in quality improvement and peer review activities
Maintain confidentiality of review information and medical records in accordance with HIPAA compliance, and Alliant Policy
Work in close collaboration with other team members to support the development of new projects and continuous improvement of the overall work process within the team
Promote core values of teamwork, professionalism, effective communication skills and positive behaviors
Maintain security and confidentiality of all information in accordance with HIPAA laws, URAC regulations, and company policies
Demonstrate compliance with the corporate and departmental policies as evidenced by attendance, punctuality, and dress
Perform other duties as assigned