Utilization Review Nurse Specialist

3 weeks ago

North Chatham, United States Albany Medical Center Full time
Job Summary

We are seeking a skilled Utilization Review Nurse to join our team at Albany Medical Center. As a key member of our Care Management department, you will play a critical role in ensuring the efficient and effective use of healthcare resources.

Key Responsibilities
  • Conduct thorough utilization reviews to identify opportunities for improvement in patient care and resource utilization.
  • Collaborate with healthcare teams to develop and implement effective care plans that meet the needs of patients and reduce unnecessary costs.
  • 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 quality department to implement changes.
  • Monitor length of stay and ancillary resource use, taking actions to achieve continuous improvement in both areas.
  • Communicate with payors and clinical staff to resolve issues and ensure seamless care transitions.
  • Use quality screens to identify potential issues and forward information to the quality department.
  • Facilitate the removal of delays and document delays when they exist, reporting internal and external delays to the Triad Team.
Requirements
  • 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.
  • Case Management certification preferred.
  • Assertive and creative problem-solving skills, critical thinking, systems planning, and patient care management.
  • 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.
What We Offer

Albany Medical Center is an equal opportunity employer and offers a competitive salary and benefits package.

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