Review Nurse-PA/UM

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.

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

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

Benefits

  • medical
  • dental
  • life
  • disability
  • paid-time off
  • retirement with match and contribution
  • employee assistance program
  • parental leave
  • other well-being resources
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