Review Nurse, Pediatric Review

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!

POSITION SUMMARY

The Pediatric Review Nurse, as a member of a professional multi-disciplinary team, 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 Pediatric Review Nurse reviews inputs accurate data entry of clinical review and decision information into the Prior Authorization (PA system), preparation of determination letters and participation in hearings when needed. Medical review addresses the necessity and the appropriateness of services utilizing the established criteria.

ESSENTIAL JOB FUNCTIONS

• Ensures that the required review documentation is complete and current; 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.
• Performs other duties as assigned.

OTHER IMPORTANT JOB FUNCTIONS

• 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 team work, 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.

KNOWLEDGE, SKILLS, AND ABILITIES

• Strong theoretical clinical knowledge base and problem-solving skills.
• Strong organizational skills with ability to demonstrate the 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, including typing skills at 30-50 WPM and data entry skills required.
• Excellent interpersonal, written and verbal skills required.
• Ability to travel as needed "driving" and/or "going on airplane to customer locations or meetings."

EDUCATION, EXPERIENCE, AND TRAINING

Required:

• Registered Nurse, with minimum of three years of recent clinical pediatric experience
• Current Georgia Nursing License

Preferred:

If interested, please apply.