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 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 inquiries 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…