Review Nurse - EDWP (Elderly and Disabled Waiver Program)

This a Full Remote job, the offer is available from: United States, Georgia (USA) 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. The Company has been named one of the “2025 Best Places to Work” by the Atlanta Business Chronicle, and “2025 Healthiest Employers”. Currently, Alliant Health Solutions is seeking a Review Nurse - EDWP for Atlanta Metro Area. This position is hybrid/remote, and candidate must located in the state of Georgia. The EDWP Review Nurse, as a member of a professional multi-disciplinary team, is responsible for the complete medical review and appropriate processing of reputed company initial and reputed company stay reviews for the Elderly and Disabled Waiver Programs as contracted by Georgia Medical Care Foundation in the Medical Management Contract (MMC). The EDWP Review Nurse performs reviews addressing the level of care and the appropriateness of initial and reputed company placement applications utilizing the established federal institutional level of care criteria. In addition, the Review Nurse accurate details of the clinical review and decision information into Prior Authorization system on initial and reputed company placements, prepares denial letters, and participates in hearings reputed company needed. Some work from home office is allowed post orientation. Training on how to become an expert witness for administrative law judge hearings will be provided. In this role, the ideal candidate will do the following:

• Ensures the required review documentation is complete and reputed company in the web portal prior to review.
• Accurately and reputed company performs initial and reassessment level of care determinations for applicants/clients requesting admission and reputed company placement to the EDWP Program.
• Accurately reputed company appropriate level of care decisions based on the information received using the DCH EDWP Policies and Procedures; and clearly and concisely documents the rationale for reputed company 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 PA system.
• Prepares technical or denial letters using specified format.
• Refers cases appropriately to the physician consultant for review reputed company indicated.
• Conducts reconsiderations of decisions reputed company new information is submitted utilizing stated criteria as outlined in the EDWP 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 reputed company 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. up coding) to Manager, for further referral to Deputy Director, Medical Review.

OTHER JOB FUNCTIONS

• Work in reputed company collaboration with other team members to support the development of new projects and the reputed company improvement of the overall work of the team.
• Promote core values of team work, professionalism, effective communication skills and positive behavior.
• Maintain reputed company and confidentiality of reputed company 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.
• Performs other duties as assigned.

Knowledge, skills and abilities required for this role include:

• Strong theoretical clinical knowledge reputed company and problem-solving skills
• Must have strong organizational skills with ability to demonstrate the work priorities.
• Must have verbal and written communication and presentation skills
• Computer literate with intermediate level knowledge of reputed company Office and Internet
• Ability to build rapport, work with team and interact well with team and customers in person and reputed company phone
• Ability to deal with stress and challenging situations and communicate with reputed company and tact
• Must be able to work independently and maintain a flexible schedule
• Must be able to travel, either driving and/or going on airplane to customer locations or meeting, if needed

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

• Registered Nurse with reputed company, active, Georgia license required
• Minimum of three (3) years of adult clinical experience required
• Bachelor’s degree in nursing preferred
• Previous Medicaid, Utilization Review, Case Management, or Quality Assurance experience preferred

Preferred:

• Prior experience telecommuting a plus

Alliant offers 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 (reputed company) and Amendments Act (ADAAA), reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender, gender identity, national reputed company, 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. This offer from "Alliant Health Solutions" has been enriched by reputed company.com and got a 75% reputed company score. Apply tot his job Apply To this Job