Review Nurse-Medical Claims

Are you a bedside nurse seeking a change from the hospital setting? If you answered "yes", Alliant Health Solutions, a "2026 Best Place to Work and Healthiest Employer", may be the place for you!

The Medical Claims Review Nurse is responsible for conducting reviews of suspended, pre-pay and reconsideration/appeals/provider inquiry/retrospective claims that require a medical review prior to adjudication.

ESSENTIAL JOB FUNCTIONS

• 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 inquires in the Alliant appeal/provider inquiry system that require a medical review of a system denial edit or an appeal of a denial adjudicated claim, to include dental appeals.
• Perform reviews accurately and efficiently within time requirements as specified and performs accurate data entry of required review-specific information.
• Evaluate submitted information and review claims that meet criteria and determine up-coding; make recommendation on appropriate level/ code based on record documentations.
• Render appropriate decisions based on the information received using the established criteria; and clearly and concisely documents the rationale for all decisions rendered.
• Utilize Gainwell interChange claims system to resolve suspended claims for adjudication and utilizes Alliant appeal/provider inquiry system to resolve reconsiderations/appeals/provider inquiries.
• Work in collaboration with Medical Review Team to oversee and support surveillance utilization review functions.
• Identify and documents suspected cases of fraud and abuse to Supervisor, for further referral to Deputy Director, Program Integrity and Medical Review.

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 behavior.
• 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.

KNOWLEDGE, SKILLS, AND ABILITIES

• Working knowledge of ICD-10-CM, CPT codes, and InterQual criteria preferred.
• Strong theoretical clinical knowledge base and problem-solving skills.
• Strong organizational skills with ability to demonstrate the work priorities.

• Demonstrate ability to perform work with considerable independence by use of creative thinking, thorough analysis of problems, and use of innovative approaches to problem resolution.

• Computer literate, including key boarding at 30-50 words per minute.
• 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:

• Registered Nurse - Current Georgia License required
• 3 years acute care clinical experience required

Preferred:

• BSN preferred
• Coding Certification preferred
• Previous claims auditing, utilization, case management, and/ or quality assurance experience preferred

PHYSICIAL REQUIREMENTS

Essential duties are routinely performed in a professional office environment but may be conducted in remote or field locations. The role may require work at a station/desk and routinely requires use of standard office equipment such as computers, phones, photocopiers/scanners, fax machines, printers, and filing cabinets. Duties may require use of transportation to attend meetings or conduct duties outside of the office environment. Must be able to regularly remain in a stationary position and occasionally move about the office to access office machinery and facilities. Occasionally must be able to move/transport materials weighing up to 30 pounds, as well as position self to access files, equipment, and work materials. This role frequently communicates to internal and external resources both verbally and written, via face-to-face, electronic, and telephonic media. Must be able to understand and exchange accurate information in these situations, as well as translate into action. Short-term and long-term memory, abstract reasoning and decision making may be required on a regular basis. Core office / business operational hours may be required.

ADA/ADAAA/SECTION 503 NOTIFICATION

In compliance with the ADA, the ADA Amendments Act (ADAAA) and Section 503 of the Rehabilitation Act), should you have a disability and would like to request reasonable accommodation, please see Human Resources to begin the interactive process.

DISCLAIMER:

This job description indicates the general nature and level of work expected of the incumbent. It is designed to cover or contain a comprehensive, but not all-inclusive, listing of activities, duties, tasks and/or responsibilities as required for Employee. Employee may be asked to perform other duties and responsibilities as required.