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Clinical Utilization Review Specialist
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Albany Medical Center is seeking a skilled Clinical Utilization Review Specialist to join our team. As a key member of our Care Management department, you will play a critical role in ensuring the quality and efficiency of patient care.
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 appropriateness of admissions and continued stays, and document findings based on departmental standards.
- Identify areas for clinical documentation improvement and work with clinical staff to implement changes.
- Monitor length of stay (LOS) and ancillary resource use, and take actions to achieve continuous improvement in both areas.
- Refer cases and issues to Medical Director and Triad Team in compliance with department procedures and follow up as indicated.
- Communicate covered day reimbursement certification for assigned patients.
- Discuss payor criteria and issues on a case-by-case basis with clinical staff and follow up to resolve problems with payors as needed.
- Use quality screens to identify potential issues and forward information to the Quality Department.
- Facilitate removal of delays and document delays when they exist. Report internal and external delays to the Triad Team.
- 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.
