Review Nurse, RN - Medicaid Utilization and Compliance Review

Job Description

Job Description

Alliant Health Group is a family of companies that provides professional services supporting the effective administration of healthcare programs and funding to support healthcare improvement initiatives.

Alliant Health Solutions provides Federal and state government entities with the services, expertise and information systems necessary to increase the effectiveness, accessibility and value of health care.

Currently, Alliant Health Solutions, a "2023 Best Place to Work and Healthiest Employer", seeks an UCR Review Nurse. The Medicaid Utilization and Compliance Review (UCR) Nurse, as a member of a professional multi-disciplinary work team, is responsible for the analysis and monitoring of policy compliance for Medicaid providers.

This position will determine an estimate of recoverable amounts by reviewing coding and billing patterns and identifying payment errors of these previously identified providers for the Department of Community Health (DCH), Office of Inspector General, Program Integrity Unit.

This position offers the opportunity to telecommute following the successful completion of orientation and training.

In this role, the ideal candidate will :

• Conducts on-site or desktop reviews through claims analysis. Review levels include initial, corrective action plan and administrative.
• Inform providers in advance of upcoming on-site visits. Conducts entrance and exit interviews with providers informing them of purpose of visit;

on-site targeted and non-targeted reviews for the specified Medicaid providers, which includes some but not all of the following : entrance and exit sessions with the appropriate management and clinical staff from the provider location, staff interviews, and scanning of document(s) to be reviewed.

• Initiates case activity log in developing the appropriate approach for the on-site review.
• Conduct on-site targeted and non-targeted reviews for the specified Medicaid providers which includes some but not all of the following : entrance and exit sessions with the appropriate management and clinical staff from the provider location, staff interviews, and scanning of document(s) to be reviewed.
• Performs member assessments / reviews of services provided and billed either on-site or telephonically.
• Make recommendations based on medical judgment and experience for the necessity of the services and the appropriateness of the setting while substantiating recommendations with clinical rationale.
• Analyze, interprets and documents appropriate determination of estimated recoverable amounts from specified Medicaid providers through review and identification of policy compliance, coding / billing patterns and payment errors.
• Prepare timely, accurate, written letters to providers / DCH on initial and final desktop review and on-site findings.
• Correction Action Plan (CAP) review of the deficiencies identified during the initial review. The provider should include a plan to correct the issues and a target date.
• Perform administrative reviews if requested by the provider. Review additional information related to requests for reconsideration after initial findings and makes a recommendation based on medical judgment and experience for the necessity of the service and the appropriateness of the setting.
• Provide support and expert testimony at Administrative Law Judge Hearings as requested by DCH’s Legal Services in support of Administrative Review findings.
• Serve occasionally on panel of peers to provide medical expertise regarding standards of medical care.
• Case Management Reviews of Independent Care Waiver Program (ICWP), Community Care Service Program (CCSP) and Service Options Using Resources in a Community Environment (SOURCE) programs.
• Special Project reviews on various provider’s types.

Other Job Functions

• Works 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.
• Promotes core values of team work, professionalism, effective communication skills and positive attitude.
• Maintains security and confidentiality of all information in accordance with HIPAA laws, regulations and company policies.
• Demonstrates compliance with corporate and departmental policies as evidenced by attendance, punctuality, and dress.
• Perform other tasks and duties assigned.

Knowledge, skills and abilities required for this role include :

• Strong theoretical clinical knowledge base and problem-solving skills.
• Strong organizational skills with ability to demonstrate work priorities.
• Demonstrated 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 with intermediate level knowledge of Microsoft Office (Word and Excel) and proven ability to type 35 WPM or more.
• Advanced interpersonal, written and verbal communication skills required.
• Advanced telephone skills, including ability to handle difficult calls / callers.
• Ability to travel as needed by driving a car and / or flying on an airplane to customer locations or meetings that may require overnight stays.

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

Required :

Registered Nurse (RN) with current Georgia license and three to five years of clinical experience

Preferred :

Bachelor’s degree in nursing, case management experience; and / or certified case manager

Knowledge of Department of Community Health (DCH)