Registered Nurse
4 months ago
Department/Unit:
Care Management/Social Work
Work Shift:
Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients.
Completes Utilization Management and Quality Screening for assigned patients.
• Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards.
• Identifies at-risk populations using approved screening tool and follows established reporting procedures.
• Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated.
• Communicates covered day reimbursement certification for assigned patients.
• Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed.
• Uses quality screens to identify potential issues and forwards information to the Quality Department.
• Facilitates removal of delays and documents delays when they exist. Collaborates with the health care team and appropriate department in the management of care across the continuum of care by assuring communication with Triad Team and health care team.
Bachelor's degree preferred
• Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management.
• Basic knowledge of computer systems with skills applicable to utilization review process.
• Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications.
• Strong analytic, data management and PC skills.
• Working knowledge of Medicare regulatory requirements, Managed Care Plans
Thank you for your interest in Albany Medical Center
Albany Medical is an equal opportunity employer.
This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.
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