Alliant Health Solutions

Nurse

• Perform complete medical review and appropriate processing of initial and continued placement level-of-care determinations for SOURCE and CCSP programs
• Review admission necessity and appropriateness using established criteria
• Ensure review documentation is complete and current in the web portal
• Perform initial and reassessment level-of-care determinations for applicants and clients
• Render level-of-care decisions using Department of Community Health SOURCE and CCSP policies and procedures
• Document rationale for nurse reviewer decisions within contract time frames
• Enter clinical review and decision information into the Prior Authorization system
• Prepare technical or denial letters using specified formats
• Refer cases to physician consultants when indicated
• Conduct reconsiderations using stated criteria and generate final decision letters
• Complete information required for appeals and fair hearings and serve as a subject matter expert when required
• Participate in provider education and performance improvement/monitoring activities
• Respond to provider questions through the established Contact Us format
• Identify and document suspected fraud and abuse for management referral
• Collaborate with team members on new projects and continuous improvement
• Maintain HIPAA and company information security and confidentiality
• Perform other assigned duties

Review Nurse, EDWP, SOURCE, CCSP