Clinical Utilization Review Specialist

1 month ago


Malden Bridge, 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/Social Work department, you will play a critical role in ensuring the efficient and effective delivery of patient care.

Key Responsibilities
  • Conduct thorough utilization reviews to identify opportunities for improvement in patient care and resource utilization.
  • Apply MCG criteria to monitor the appropriateness of admissions and continued stays, and document findings in accordance with departmental standards.
  • Collaborate with healthcare teams to identify areas for clinical documentation improvement and implement changes as needed.
  • Utilize approved screening tools to identify at-risk populations and develop strategies for improvement.
  • 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.
  • Facilitate the removal of delays and document delays when they exist.
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.
About Albany Medical Center

Albany Medical Center is an equal opportunity employer committed to providing a work environment that is free from discrimination and harassment. We are dedicated to fostering a culture of inclusivity, respect, and professionalism.



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