Review Nurse, Pediatric Review

Overview Are you a bedside nurse seeking a change from the hospital setting? Position Summary The Pediatric Review Nurse, as a member of a professional multi-disciplinary team, is responsible for the complete medical review for Pediatric Programs as contracted by Alliant Health Solutions in the Medical Management and Utilization Review Contract (MMURS). The Pediatric Review Nurse reviews inputs, accurate data entry of clinical review and decision information into the Prior Authorization (PA) system, preparation of determination letters, and participation in hearings when needed. Medical review addresses the necessity and the appropriateness of services utilizing the established criteria. Responsibilities Ensure that the required review documentation is complete and current; maintain an organized and complete electronic record on each Medicaid member/applicant. Accurately render appropriate determinations based on the information received using the DCH policies and guidelines; clearly document the rationale for all nurse reviewer decisions within applicable contract time frame requirements. Openly refer cases to a Peer Consultant per policy and guidelines. Process all Change Requests and Reconsideration Reviews on a daily basis. Prepare determination letters to applicants using appropriate business format. Perform accurate data entry of clinical review and decision information into the PA system. Respond to provider inquiries through the “Contact Us” mechanism within established time frames. Conduct re-evaluations and review of appeals utilizing stated criteria as outlined in DCH Policy Manuals; complete summary information required for appeals and fair hearings in a timely manner and attend/participate in hearings when required. Assist providers with resolution of claims edit issues as needed. Complete required review activity within contractual specifications and deadlines. Identify and document suspected cases of fraud and abuse to Manager, for further referral to Director, Utilization Review Services. Perform other duties as assigned. Other Important Job Functions May perform medical record reviews per policy for Georgia Pediatric Program (GAPP), Katie Beckett (KB), Children's Intervention Services (CIS), and Autism Spectrum Disorder Program (ASD) or other programs as needed. Work in close collaboration with other team members to support the development of new projects and the continuous improvement of the overall work of the team. Promote core values of teamwork, professionalism, effective communication skills and positive behavior. Maintain security and confidentiality of all information in accordance with HIPAA laws, regulations, and company policies. Demonstrate compliance with corporate and departmental policies as evidenced by attendance, punctuality, and professional appearance. Knowledge, Skills, and Abilities Strong theoretical clinical knowledge base and problem-solving skills. Strong organizational skills with ability to manage work priorities. Demonstrated ability to work with considerable independence by using creative thinking, thorough analysis of problems, and innovative approaches to problem resolution. Computer literacy, including typing skills at 30-50 WPM and data entry skills required. Excellent interpersonal, written and verbal skills required. Ability to travel as needed, including driving and/or travel by airplane to customer locations or meetings. Education, Experience, and Training Required: Registered Nurse, with a minimum of three years of recent clinical pediatric experience Current Georgia Nursing License Preferred: Bachelor's degree in Nursing #J-18808-Ljbffr