Utilization Review Nurse

Elderly And Disabled Waiver Program Review NurseAre you a bedside nurse seeking a change from the hospital setting? If you answered "yes", Alliant Health Solutions, a "2026 Best Place to Work and Healthiest Employer", may be the place for you!In this position, the ideal candidate will:Review Nurse, Elderly and Disabled Waiver Program (EDWP) Review Nurse for (SOURCE) Service Options Using Resources in a Community Environment and (CCSP) Community Care Service Program, as a member of a professional multi-disciplinary work team, is responsible for the complete medical review and appropriate processing of all initial and continued placement level of care (LOC) determinations for the SOURCE (Service Options Using Resources in Community Environments) and CCSP (Community Care Services) Program in the Georgia Medical Management and Utilization Review contract. Medical review addresses the necessity and the appropriateness of the admission utilizing the established criteria.Essential Job FunctionsEnsures the required review documentation is complete and current in the web portal prior to review.Accurately and efficiently performs initial and reassessment level of care determinations for applicants/clients requesting admission and continued placement to the SOURCE or CCSP Program.Accurately render appropriate level of care decisions based on the information received using the Department of Community Health (DCH) SOURCE and CCSP Policies and Procedures; and clearly and concisely documents the rationale for all nurse reviewer decisions in the web portal and in accordance with applicable time frame requirements of the contract.Performs accurate data entry of clinical review and decision information into Prior Authorization (PA) system.Prepares technical or denial letters using specified format.Refers cases appropriately to the physician consultant for review when indicated.Conducts reconsiderations of decisions when new information is submitted utilizing stated criteria as outlined in the SOURCE and CCSP Manual and generates final decision letters.Completes summary information required for appeals and fair hearings in a timely manner and serves as a subject matter expert in hearings when required.Participates in provider education and performance improvement/monitoring activities as required.Responds to provider questions through "Contact Us" established format.Identifies and documents suspected cases of fraud and abuse (e.g., upcoding) to Manager Waiver Programs, for further referral to Director Utilization Review Services.Other Job FunctionsWork 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 behaviorMaintain 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.Performs other duties as assigned.Knowledge, Skills, and AbilitiesStrong theoretical clinical knowledge base and problem-solving skills.Must have strong organizational skills with ability to demonstrate the work priorities.Must have verbal and written communication and presentation skillsComputer literate with intermediate level knowledge of Microsoft Office and InternetAbility to build rapport, work with team and interact well with team and customers in person and via phoneAbility to deal with stress and challenging situations and communicate with empathy and tactMust be able to work independently and maintain a flexible scheduleMust be able to travel as needed "driving" and/or "going on airplane to customer locations or meetings"Education, Experience, and TrainingRegistered Nurse with current, active, Georgia license required, with Bachelor's degree in nursing preferredMinimum of three to five years of adult medicine clinical experience requiredPrevious Medicaid, Utilization Review, Case Management, or Quality Assurance experience preferredPrior experience telecommuting a plus.Physical Requirements:Essential duties are routinely performed in a professional office environment but may be conducted in remote or field locations. The role may require work at a station/desk and routinely requires use of standard office equipment such as computers, phones, photocopiers/scanners, fax machines, printers, and filing cabinets. Duties may require use of transportation to attend meetings or conduct duties outside of the office environment. Must be able to regularly remain in a stationary position and occasionally move about the office to access office machinery and facilities. Occasionally must be able to move/transport materials weighing up to 30 pounds, as well as position self to access files, equipment and work materials. This role frequently communicates to internal and external resources both verbally and written, via face-to-face, electronic and telephonic media. Must be able to understand and exchange accurate information in these situations, as well as translate into action. Short-term and long-term memory, abstract reasoning and decision making may be required on a regular basis. Core office / business operational hours may be requiredADA/ADAAA/SECTION 503 Notification:In compliance with the ADA, the ADA Amendments Act (ADAAA) and Section 503 of the Rehabilitation Act), should you have a disability and would like to request a reasonable accommodation, please see Human Resources to begin the interactive process.DisclaimerThis job description indicates the general nature and level of work expected of the incumbent. It is designed to cover or contain a comprehensive, but not all-inclusive, listing of activities, duties or responsibilities required of the incumbent. Incumbent may be asked to perform other duties as required.