Hybrid Review Nurse (RN/PA) – Prior Authorization

Alliant-Health-Solutions-1; Atlanta (GA); Hybrid; USD 85,000 - 110,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Life insurance

Disability insurance

Paid time off

Retirement match

Employee assistance program

Parental leave

Job summary

Alliant Health Solutions is hiring a Hybrid Review Nurse for its PA/UM team in Atlanta, GA. The role reviews provider prior approvals and precertifications for Georgia Medicaid, with emphasis on InterQual criteria and nursing judgment.

The ideal candidate holds a Georgia RN license, 3+ years of clinical experience, and strong communication skills. The position includes collaboration with medical directors and participation in quality improvement efforts within a supportive environment.

Qualifications

• 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

Responsibilities

• 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

Skills

InterQual criteria knowledge

Clinical problem-solving

Organizational skills

Communication skills

Typing speed 30-50 wpm

MS Windows proficiency

Independent work

Travel readiness

Education

Georgia nursing license

Three years clinical experience

Tools

InterQual criteria

Job description

Alliant Health Solutions is hiring a Hybrid Review Nurse for its PA/UM team in Atlanta, GA. The role reviews provider prior approvals and precertifications for Georgia Medicaid, with emphasis on InterQual criteria and nursing judgment.

The ideal candidate holds a Georgia RN license, 3+ years of clinical experience, and strong communication skills. The position includes collaboration with medical directors and participation in quality improvement efforts within a supportive environment.