Review Nurse, Independent Care Waiver Program (ICWP)

Alliant Health Solutions, Inc.•Atlanta, GA

21h•Remote

About The Position

The ICWP Review Nurse, as a member of a professional multi-disciplinary work team, is responsible for the complete medical review and appropriate processing of all pre-admission, level change and continued placement reviews for the Independent Care Waiver Program (ICWP) as contracted by Alliant Health Solutions. Medical review addresses the necessity and the appropriateness of the admission or continued placement utilizing the established criteria.

Requirements

Registered Nurse (RN) or Licensed Practical Nurse (LPN) with active, unencumbered Georgia license
3 years of relevant clinical experience (e.g., adult medicine, home health, community health, utilization review, or care management)
Knowledge of ICD-10-CM and DCH program regulations governing GAPP Policies and Procedures.
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
Strong computer knowledge and technical skills including but not limited to: typing skills at 30-40 WMP, data entry, and managing and reviewing electronic health information.
Ability to work remotely efficiently.
Excellent interpersonal, written, and verbal skills required.
Must be able to travel as needed for assessments and meetings with our customers in the State of Georgia.

Nice To Haves

Home Health and Community Health experience
Knowledgeable of State Medicaid Waiver programs
Experience with utilization management, medical review, or prior authorization

Responsibilities

Ensure that the required review documentation is complete and current; and maintains an organized and complete electronic record on each ICWP member.
Perform off-site or video (telehealth) nursing assessments when required and complete the DON screening tool to determine if candidate meets criteria for admission into program.
Accurately and efficiently perform pre-admission, level change and continued placement reviews for applicants/clients related to the Independent Care Waiver (ICWP) program.
Accurately render appropriate level of care decisions based on the information received using the DCH ICWP Policies; and clearly and concisely documents the rationale for all nurse reviewer decisions in accordance with applicable time frame requirements of the contract.
Prepares denial letters to applicants using appropriate business format.
Perform accurate data entry of clinical review and decision information into PA system.
Completes required review activity within contractual deadlines within established time frames.
Responds to provider inquiries through “Contact Us” mechanism.
Refer cases appropriately to the physician consultant for review when indicated.
Conduct re-evaluations and review of appeals utilizing stated criteria as outlined in the ICWP Manual, completes summary information required for appeals and fair hearings in a timely manner, and attends/participates in hearings when required.
Assists providers with resolution of claims edit issue as needed.
Participates in providing education as required.
Identifies and document suspected cases of fraud and abuse to Team Leader, for further referral to Deputy Director, Medical Review.
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 teamwork, professionalism, effective communication skills and positive attitude.
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.
Performs other duties as assigned