Clinical Utilization Specialist
4 days ago
We are seeking a skilled Clinical Utilization Specialist to join our team at Albany Medical Center. As a key member of our Care Management/Social Work department, you will play a critical role in ensuring the highest quality patient care while optimizing resource utilization.
Key Responsibilities- Conduct thorough utilization reviews to identify opportunities for improvement in patient care and resource allocation.
- Collaborate with healthcare teams to develop and implement effective care plans that meet the unique needs of each patient.
- Apply MCG criteria to monitor the appropriateness of admissions and continued stays, and document findings in accordance with departmental standards.
- Identify areas for clinical documentation improvement and work with the appropriate departments to implement changes.
- Monitor length of stay (LOS) and ancillary resource use, taking proactive steps to achieve continuous improvement in both areas.
- Communicate with payors to resolve issues and ensure timely reimbursement for assigned patients.
- Use quality screens to identify potential issues and forward information to the Quality Department for further review.
- Registered nurse with a New York State current license.
- Bachelor's degree preferred.
- Minimum of three years clinical experience in an assigned service.
- Recent experience in case management, utilization management, and/or discharge planning/home care in a high-volume, acute care hospital preferred.
- Assertive and creative problem-solving skills, critical thinking, systems planning, and patient care management expertise.
- Self-directed with the ability to adapt in a changing environment.
- Basic knowledge of computer systems with skills applicable to utilization review process.
- Excellent written and verbal communication skills.
- Working knowledge of MCG criteria and ability to implement and utilize.
- Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications.
- Ability to work independently and demonstrate organizational and time management skills.
- Strong analytic, data management, and PC skills.
- Working knowledge of Medicare regulatory requirements, Managed Care Plans.
Albany Medical Center 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.
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West Sand Lake, New York, United States Albany Medical Center Full time{"title": "Clinical Utilization Specialist", "content": "Job SummaryAlbany Medical Center seeks a skilled Clinical Utilization Specialist to join our Care Management team. In this role, you will be responsible for ensuring the efficient and effective use of healthcare resources while maintaining high-quality patient care.Key ResponsibilitiesConduct thorough...
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