Referral Coordinator, Registered Nurse

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.

Currently, Alliant Health Solutions, a "2024 Best Place to Work and Healthiest Employer", seeks a Referral Coordinator. The Referral Coordinator will review and process Prior Authorizations (PA) and related appeal requests. The Referral Coordinator will also evaluate Nurse Reviewer referrals and obtain timely reviews by Peer Review Consultants (Physicians and other Allied Health Professionals) for cases that do not meet criteria. The essential job functions or responsibilities of the Referral Coordinators are listed below:

In this role, the ideal candidate will:

• Perform pre-procedure and emergency reviews on various medical specialties such as inpatient and outpatient procedures/care, medications, DME, office visits, therapies, transportation, and long-term care treatment. Processes these reviews accurately and within applicable time frames.
• Document the rationale clearly for all nurse reviewer decisions using appropriate criteria and refers cases correctly.
• Evaluate Nurse Reviewer referrals and Provider reconsideration. Referral Coordinators approve cases that meet criteria or use experience and nursing judgment, when appropriate, to overturn Nurse Reviewer referrals and provider reconsideration. Referral Coordinators review cases that fail these screens to the appropriate Peer Consultant.
• Obtain timely specialty-to-specialty review of referred cases, and complete and process the review in a timely manner.
• Coordinate in-house MD review by specialty via web and phone with an appropriate Peer Review Consultant.
• Consult with Medical Directors on issues related to Peer Consultant review decisions.
• Coordinate between providers and PA/UM staff to trouble shoot problematic cases and requests for supervisor or call backs or requests for medical director peer consultant decisions.
• Participate in Administrative Review process and Legal Hearing court cases as an expert in PA/UM process
• Conduct re-evaluations and reconsiderations utilizing stated criteria and complete summary information required for consultant reconsiderations and fair hearings in cooperation with DCH.
• Ensure appropriate provider denial or approval notification of review status in specialty cases like Out of State or Psychiatric Residential Treatment Facility stays with majority of decision notices generated automatically through Gainwell Technologies MMIS system.
• Serve as a resource for staff and assist in staff training.
• Participate in Peer Consultant onboarding and job/system training as needed.
• Maintain confidentiality of review information and medical records in accordance with Health Information Portability and Accountability Act (HIPAA) regulations and company policy.
• Oversee and/or draft provider denial or approval letters and provider notification of review status in specified cases.

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 required for this role include:

• Knowledge, skill and ability to demonstrate considerable independence by use of creative thinking, thorough analysis of problems, and use of innovative approaches to problem resolution
• Knowledge, skill and ability to manage time, organize work and work priorities
• Knowledge and skill of theoretical clinical knowledge base and problem-solving skill
• Knowledge skill and ability to communicate in verbal and written formats
• Skill and ability to build relationships, collaborate and work with a team
• Working knowledge of ICD-10-CM, CPT codes, and InterQual criteria preferred
• Computer literate, including typing skills at 30-50 WMP and data entry skills
• Ability to travel by car or plane to Company locations, customer meetings or other locations as needed

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

Required:

• Registered Nurse with current and unencumbered Georgia Nursing license
• At least three (3) years of recent clinical experience

Preferred:

• Bachelor of Science in Nursing
• Previous Case Management, Utilization Management, or Prior Authorization experience
• Previous healthcare, government and/or nonprofit experience

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 to apply for the position.

Alliant Health Group ("the Company) is an Affirmative Action, 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.