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Clinical Utilization Review Specialist
2 months ago
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 be responsible for ensuring the efficient and effective use of healthcare resources.
Key Responsibilities- Conduct thorough reviews of patient records to identify opportunities for improvement in clinical documentation and resource utilization.
- Collaborate with healthcare teams to develop and implement plans to reduce length of stay and ancillary resource use.
- Communicate with payors to resolve issues and ensure compliance with regulatory requirements.
- Identify and report potential quality issues to the Quality Department.
- Participate in case reviews and inter-rater reliability studies to ensure accurate application of MCG criteria.
- Facilitate the removal of delays and document delays when they exist.
- 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.
