Clinical Utilization Review Specialist

3 days ago


Cohoes, New York, United States Albany Medical Center Full time
Job Summary

We are seeking a highly skilled Clinical Utilization Review Specialist 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 quality and efficiency of patient care.

Key Responsibilities
  • Conduct thorough utilization reviews to ensure medical necessity and appropriateness of patient admissions and continued stays.
  • Apply MCG criteria to monitor and document findings, identifying areas for clinical documentation improvement and collaborating with the clinical team to implement changes.
  • Identify at-risk populations using approved screening tools and develop strategies to mitigate risks.
  • Monitor length of stay (LOS) and ancillary resource use, taking proactive steps to achieve continuous improvement.
  • Communicate with payors to resolve issues and ensure timely reimbursement.
  • Collaborate with the healthcare team to ensure seamless care transitions and optimal patient outcomes.
Requirements
  • Registered Nurse with a current New York State license.
  • Bachelor's degree preferred.
  • Minimum of three years of clinical experience in an acute care hospital setting.
  • Recent experience in case management, utilization management, and/or discharge planning/home care preferred.
  • Case Management certification preferred.
  • 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.
What We Offer

Albany Medical Center is an equal opportunity employer. This role may require access to sensitive information, and we expect our workforce members to ensure that access is based on a 'need to know' and is the minimum necessary to properly perform assigned duties.



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