Review Nurse, UCR & Medical Claims

Are you interested in joining a company with a great culture, and rated a "Best Place to Work" and "Healthiest Employer" by the the Atlanta Business Chronicle? If you answered yes, this may be the opportunity for you!

Currently, Alliant Health Solutions is seeking a Review Nurse, Utilization and Compliance Review (UCR) and Medical Claims. This position is hybrid, and candidate must be located in the state of Georgia. The Review Nurse, UCR & Medical Claims Nurse is a member of a professional multi- disciplinary work team, and 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. Position is also responsible for conducting medical claim reviews of suspended, pre-pay and reconsideration/appeals/provider inquiries/retrospective claims that require a medical review prior to adjudication. This position is hybrid (office/onsite and remote).

In this role, the ideal candidate will do the following:

• Conducts on-site or desktop reviews through claims analysis. Review levels include initial, corrective action plan (CAP), 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.
• On-site facility tours and adhere to DCH policies.
• 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.
• Provide assistance in preparing referrals for submission to the Medicaid Fraud and Patient Protection Division (MFPPD).
• 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.
• Home Community Based Services (HCBS) Quality Reviews of the waiver programs for adhere to the DCH State Transition Plan.
• Adjudicate suspended claims in the Gainwell Interchange system that require a medical review to ensure quality of care and appropriateness of services based on current standards of care.
• Adjudicate claims for providers placed on pre-payment review.
• Process Medical claim appeals/provider inquires in the Alliant appeal/provider inquiries system that requires a medical review of a system denial edit or an appeal of a denial adjudicated claim, to include dental appeals.
• Perform reviews accurately and efficiently within time requirements as specified and performs accurate data entry of required review-specific information.
• Evaluate submitted information and review claims that meet criteria and determine up-coding; make recommendation on appropriate level/ code based on record documentations.
• Render appropriate decisions based on the information/clinical documentation received using the established criteria; and clearly and concisely documents the rationale for all decisions rendered.
• Utilize Gainwell Interchange claims system to resolve suspended claims for adjudication and utilizes Alliant appeal/provider inquiry system to resolve reconsiderations/appeals/provider inquiries.
• Work in collaboration with Medical Review Team to oversee and support surveillance utilization review functions.
• Identify and documents suspected cases of fraud and abuse to Supervisor, for further referral to Deputy Director, Program Integrity, and Medical Review.
• Special Project reviews on various provider's types; and other duties as assigned.

Knowledge, skills and abilities required for this position include:

• Working knowledge of ICD-10-CM, CPT codes, and InterQual criteria preferred.
• 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 with intermediate level knowledge of Microsoft Office (Word and Excel) and proven ability to type 35 WPM or more.
• Excellent interpersonal, written, and verbal communication skills required.
• Excellent 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 for this position include:

Required:

• Registered Nurse - Current Georgia License
• 3 to 5 years acute care clinical experience

Preferred:

• Bachelor's degree in nursing, case management experience; and/or certified case manager
• Previous Utilization, Case Management, Quality Assurance and/or claims auditing experience.
• Coding Certification
• Knowledge of Department of Community Health (DCH)
• Prior telecommuting/remote work experience

Alliant knows people thrive when they feel supported, so we offer flexibility, work/life balance and great benefits including medical, dental life, disability, paid-time off, retirement with match and contribution, disability, employee assistance program, parental life, and more. If interested, click the apply icon above to apply.

Alliant Health Group ("the Company) is an Equal Opportunity Employer and Drug Free Workplace. In compliance with the American's 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.