Review Nurse, Independent Care Waiver Program (ICWP)

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 -Independent Care Waiver Program (ICWP) for Atlanta Metro Area. This position is hybrid/remote, and candidate must located in the state of Georgia.

The candidate for this position must be located in the Atlanta, GA metro area and upon completion of training position will be hybrid, offering work/life balance and excellent benefits.

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.

ESSENTIAL JOB FUNCTIONS:

• 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 nursing assessments when required and participates in candidate scoring session 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 provider education as required.
• Identifies and document suspected cases of fraud and abuse to either the Manager Waiver Programs and/or Director of Utilization Review Services.

OTHER JOB FUNCTIONS:

• 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 and regulations and company policies.
• Demonstrate compliance with company corporate and departmental policies as evidenced by attendance, punctuality, and dress.
• Perform other duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES:

• Knowledge of ICD-10-CM and DCH program regulations governing GAPP Policies and Procedures preferred.
• 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 have be able to travel as needed "driving" and/or "going on airplane to customer locations or meetings"

EDUCATION, EXPERIENCE, AND TRAINING:

Required

• RN with current Georgia license required
• At least 3 years of clinical experience required
• Must have the ability to travel via car throughout the state specifically the following counties: DeKalb, Rockdale, Newton, Henry, Butts, Jasper, Pike, and Lamar.
• There may be times you will be required to travel to other areas of the state with notice.

Preferred

• Home Health and Community Health experience preferred
• Previous Utilization review and prior authorization experience preferred