Clinical Utilization Review Specialist

1 week ago


Greenbush, Maine, United States Albany Medical Center Full time
Job Title: Utilization Review Nurse

Albany Medical Center is seeking a skilled Utilization Review Nurse to join our team.

Job Summary:

We are looking for a highly motivated and detail-oriented Utilization Review Nurse to work in our Care Management/Social Work department. The successful candidate will be responsible for conducting utilization reviews, quality screenings, and delay management for assigned patients.

Key Responsibilities:
  • Conduct utilization reviews and quality screenings for assigned patients to ensure appropriate care and resource utilization.
  • 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 contact appropriate departments as needed.
  • Monitor length of stay (LOS) and ancillary resource use, taking actions to achieve continuous improvement.
  • Refer cases and issues to the Medical Director and Triad Team in compliance with department procedures.
  • 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, 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.

This role may require access to sensitive information, including HIPAA Protected Health Information. Workforce members are expected to ensure that access to information is based on a 'need to know' and is the minimum necessary to properly perform assigned duties.



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