Review Nurse-PA/UM

Hybrid 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!Alliant 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. The primary responsibilities of the Nurse Reviewers are listed below.In this position, the ideal candidate will:Perform reviews of provider prior approval/precertification requests as per PAUM policy and proceduresEvaluate initial clinical information and approve cases that meet criteria. Document clearly the rationale for all review decisions using appropriate criteria or nursing judgmentRefer 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 approveConsult with the Manager, Supervisor PA/UM, or Medical Directors on issues related to Peer Consultant review decisions or cases requiring physician clarificationParticipate in quality improvement and peer review activitiesMaintain confidentiality of review information and medical records in accordance with HIPAA compliance, and Alliant PolicyWork in close collaboration with other team members to support the development of new projects and continuous improvement of the overall work process within the teamPromote core values of teamwork, professionalism, effective communication skills and positive behaviorsMaintain security and confidentiality of all information in accordance with HIPAA laws, URAC regulations, and company policiesDemonstrate compliance with the corporate and departmental policies as evidenced by attendance, punctuality, and dressPerform other duties as assignedKnowledge, skills and abilities required for this position include:Knowledge of ICD-10-CM, CPT codes, and InterQual criteria preferredKnowledge of clinical theory and problem-solving skillsStrong organizational skills with ability to demonstrate the work prioritiesExcellent interpersonal, written, and verbal skills requiredKnowledge, 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 resolutionComputer literate, experience with MS Windows productsAbility to type 30-50 words per minuteAbility to travel by car or plane to Company locations, customer meetings or other locations as neededEducation, experience and training required and preferred for the position are below:Required:Registered Nurse, with at least three years of recent clinical experience requiredCurrent and unencumbered Georgia nursing license requiredPreferred:Utilization Review or Prior Approval Precertification experienceAlliant knows that people thrive when they feel supported, so we offer work/life balance, competitive benefits including medical, dental life, disability, paid-time off, retirement with match and contribution, disability, employee assistance program, parental leave, and other well-being resources.