Review Nurse-PA/UM

Hybrid Review Nurse

Are you a bedside nurse seeking a change from the hospital setting? If you answered "yes", Alliant Health Solutions, a "2025 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 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

Knowledge, skills and abilities required for this position include:

• Knowledge of ICD-10-CM, CPT codes, and InterQual criteria preferred
• 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

Education, experience and training required and preferred for the position are below:

Required:

• Registered Nurse, with at least three years of recent clinical experience required
• Current and unencumbered Georgia nursing license required

Preferred:

• Utilization Review or Prior Approval Precertification experience

Alliant 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. If interested, click the apply icon above to apply. Alliant Health Group and subsidiaries, dba Alliant Health Solutions ("the Company) is an Equal Opportunity Employer and Drug Free Workplace. In compliance with the American's with Disability Act (ADA) and Amendments Act (ADAAA), all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender, gender identity, national origin, disability or veteran status. If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, please let us know. Likewise, if you are limited in the ability to access or use this online application process and need an alternative method for applying, we will determine an alternative method for you to apply. Please contact View phone number on click.appcast.io.