Pediatric Review Nurse or Therapist (Hybrid Position)

Job Description

Job Description

Alliant Health Group, doing business as Alliant Health Solutions ("the Company"), is a family of companies that provides business and professional services supporting the effective administration of healthcare programs and funding to support healthcare improvement initiatives.

The Company has been named a "Best Place to Work" for 2022, 2023, and 2024 as well as being named "Healthiest Employer".

Currently, A lliant seeks a Pediatric Review Nurse or Therapist. As a member of a professional multi-disciplinary team, the Review Nurse or Review Therapist 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 Review Nurse or Therapist evaluates, reviews and inputs accurate data entry of clinical review and decision information into the Prior Authorization (PA system), preparation of determination letters and participation in hearings, if needed. Medical review addresses the necessity and the appropriateness of services utilizing the established criteria.

In this role, the ideal candidate will :

• Review documentation for accuracy and completeness, and maintains an organized and complete electronic record on each Medicaid member / applicant.
• Accurately renders appropriate determinations based on the information received using the DCH policies and guidelines; and clearly and concisely documents the rationale for all nurse reviewer decisions in accordance within the applicable time frame requirements of the contract.
• Appropriately refers cases to a Peer Consultant per policy and guidelines.
• Process all Change Requests and Reconsideration Reviews on a daily basis.
• Prepares determination letters to applicants using appropriate business format.
• Performs accurate data entry of clinical review and decision information into PA system.
• Responds to provider inquiries through “Contact Us” mechanism within established time frames.
• Conducts re-evaluations and review of appeals utilizing stated criteria as outlined in DCH Policy Manuals; completes summary information required for appeals and fair hearings in a timely manner and attend / participates in hearings when required.
• Assists providers with resolution of claims edit issues as needed.
• Completes required review activity within contractual specification & deadlines.
• Identifies and documents suspected cases of fraud and abuse to Manager, for further referral to Director, Utilization Review Services.
• 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.
• Performs other responsibilities, tasks and duties as assigned.

Knowledge, skills, abilities, education, experience and training for the role include :

The Company offers a caring and supportive culture with work / life balance and great benefits!

In you are interested in joining a great team, select the "Apply" icon below!

Alliant Health Group ("the Company) is an Equal Opportunity Employer and Drug Free Workplace. In compliance with the Americans' 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 678-527-3000.