[Hiring] Review Nurse @Alliant Health Solutions, Inc.

Role Description

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", is the place for you!

The Review Nurse, Medical Frailty, conducts clinical medical record reviews for Medicaid applicants and members referred by the Georgia Department of Community Health (DCH) under the Medical Frailty contract. As a member of a multidisciplinary team, the nurse evaluates available clinical evidence, identifies additional documentation needs, applies DCH-approved Medical Frailty criteria, and documents findings and determinations within authorized nursing scope and approved decision rules. The nurse coordinates with member outreach staff and physician reviewers to support timely, consistent determinations returned to DCH for downstream eligibility processing.

Responsibilities are performed following DCH-approved policies, contract requirements, confidentiality standards, and established quality expectations.

Essential Job Functions:

• Review assigned DCH Medical Frailty referrals and supporting clinical information for completeness and correct member and case association; identify missing or conflicting evidence.
• Assess diagnoses, treatment history, condition severity, functional limitations, behavioral health and substance use information, significant health-care utilization, and reliance on life-sustaining treatment, as supported by records from the applicable DCH-approved look-back periods for each category.
• Consistently apply approved criteria, evidence standards, clinical policies, and decision rules.
• Identify the specific clinical information needed to complete the review and coordinate with member outreach and documentation procurement staff to obtain relevant records or clarification through approved processes.
• Communicate with members, authorized representatives, and providers as assigned using approved instructions and secure channels.
• Assess and document the evidence reviewed, applicable criteria, clinical findings, information gaps, and a clear rationale for each determination in the designated case record; maintain a complete history of review of actions and communications.
• Render and document Medical Frailty determinations within authorized nursing scope and DCH-approved decision rules.
• Refer cases requiring physician judgment, peer review, or policy clarification to the designated physician reviewer, Medical Director, or supervisor; incorporate the authorized final decision into the case record.
• Evaluate and approve the approved Medical Frailty disposition and supporting rationale accurately and support return of the completed determination to DCH through the approved workflow for downstream eligibility processing.
• Prepare and issue Medical Frailty determination notices and assigned clinical activities for appeals, including organizing records, reviewing additional evidence, and coordinating required physician review, in accordance with DCH-approved procedures and role assignments.
• Manage assigned review queues to meet established contract turnaround-time and quality requirements; promptly notify the supervisor of missing information, unresolved clinical questions, system issues, or other barriers to timely completion.
• Participate in quality assurance, peer review, reviewer training, and clinical consistency activities; identify recurring documentation gaps and opportunities to improve the Medical Frailty review process.
• Protect confidential member information and medical records in accordance with HIPAA, applicable privacy requirements, Alliant policies, and DCH-approved secure systems and information exchange procedures.

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 behaviors.
• 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.

Qualifications

• Strong clinical knowledge and ability to interpret medical records across complex physical health, behavioral health, substance use, and functional impairment presentations.
• Ability to apply DCH-approved Medical Frailty criteria and evidence standards, distinguish documented findings from unsupported assumptions, and recognize when additional evidence or physician review is needed.
• Working knowledge of medical terminology and ICD-10-CM coding; experience interpreting claims or other clinical data preferred.
• Strong analytical and problem-solving skills with the ability to synthesize information from multiple records and document concise, defensible clinical rationales.
• Strong organizational skills with the ability to prioritize case reviews, track documentation needs, and meet established turnaround-time and quality requirements.
• Proficiency with electronic medical records, clinical review systems, standard office applications, accurate typing and data entry, and secure document handling.
• Excellent written, verbal, interpersonal, and telephone communication skills, including the ability to request clinical clarification and communicate respectfully with members, representatives, providers, and team members.
• Ability to work independently within defined nursing authority, collaborate with outreach and physician review staff, and maintain confidentiality of sensitive clinical information.
• Ability to travel by car or plane to Company locations, customer meetings or other locations as needed.

Education, Experience, and Training

• Registered Nurse - Current Georgia License required with bachelor's in nursing preferred.
• Three to five years of recent clinical experience required.
• Previous medical record review, utilization review, or clinical determination experience desirable; experience reviewing complex medical conditions, behavioral health, substance use disorders, or functional limitations preferred.

Physical 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 around 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 a 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 or responsibilities required of the incumbent. Incumbent may be asked to perform other duties as required.