Remote Review Nurse: SOURCE/CCSP Utilization

Alliant-Health-Solutions-1; Atlanta (GA); On-site; USD 70,000 - 90,000; Full time

Job summary

Alliant Health Solutions is seeking a Review Nurse for the Elderly and Disabled Waiver Program (EDWP) and SOURCE/CCSP in Atlanta, GA. You will perform complete medical reviews and determine level of care for admissions and continued placement across SOURCE and CCSP, ensuring accurate documentation and timely decisions.

Qualified candidates are RNs with active GA licenses and 3–5 years of adult medicine experience; Medicaid/utilization review exposure is a plus.

Qualifications

• Registered Nurse with current, active Georgia license required, with Bachelor’s degree in nursing preferred
• Minimum of three to five years of adult medicine clinical experience required
• Previous Medicaid, Utilization Review, Case Management, or Quality Assurance experience preferred
• Prior experience telecommuting a plus.

Responsibilities

• Ensures the required review documentation is complete and current in the web portal prior to review.
• Accurately and efficiently performs initial and reassessment level of care determinations for applicants/clients requesting admission and continued placement to the SOURCE or CCSP Program.
• Accurately render appropriate level of care decisions based on the Department of Community Health (DCH) SOURCE and CCSP Policies and Procedures; and clearly and concisely documents the rationale for all nurse reviewer decisions in the web portal and in accordance with applicable time frame requirements of the contract.
• Performs accurate data entry of clinical review and decision information into Prior Authorization (PA) system.
• Prepares technical or denial letters using specified format.
• Refers cases appropriately to the physician consultant for review when indicated.
• Conducts reconsiderations of decisions when new information is submitted utilizing stated criteria as outlined in the SOURCE and CCSP Manual and generates final decision letters.
• Completes summary information required for appeals and fair hearings in a timely manner and serves as a subject matter expert in hearings when required.
• Participates in provider education and performance improvement/monitoring activities as required.
• Responds to provider questions through “Contact Us” established format.
• Identifies and documents suspected cases of fraud and abuse (e.g., upcoding) to Manager Waiver Programs, for further referral to Director Utilization Review Services.

Skills

Clinical knowledge

Organizational skills

Communication skills

Office software

Team collaboration

Empathy and tact

Independent work

Education

Georgia RN license

Bachelor’s degree in nursing

Tools

Microsoft Office

Internet

Job description

Alliant Health Solutions is seeking a Review Nurse for the Elderly and Disabled Waiver Program (EDWP) and SOURCE/CCSP in Atlanta, GA. You will perform complete medical reviews and determine level of care for admissions and continued placement across SOURCE and CCSP, ensuring accurate documentation and timely decisions.

Qualified candidates are RNs with active GA licenses and 3–5 years of adult medicine experience; Medicaid/utilization review exposure is a plus.