Utilization Review Nurse Specialist
6 days ago
We are seeking a skilled Utilization Review Nurse to join our team at Albany Medical Center. As a Utilization Review Nurse, you will play a critical role in ensuring the efficient and effective use of healthcare resources.
Key Responsibilities- Conduct thorough reviews of patient cases to determine medical necessity and appropriateness of care.
- Apply MCG criteria to monitor and improve the quality of care, reducing unnecessary hospital stays and resource utilization.
- Collaborate with healthcare teams to identify areas for clinical documentation improvement and implement changes to optimize patient outcomes.
- Identify at-risk populations and develop strategies to improve care coordination and reduce hospital readmissions.
- Monitor length of stay (LOS) and ancillary resource use, taking proactive steps to achieve continuous improvement.
- Communicate with payors and healthcare teams to resolve issues and ensure seamless care transitions.
- Utilize quality screens to identify potential issues and report findings to the Quality Department.
- Participate in case reviews and inter-rater reliability studies to ensure accurate and consistent application of MCG criteria.
- Facilitate removal of delays and document delays when they exist, reporting to the Triad Team as needed.
- 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.
- 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.
This role may require access to sensitive information, including HIPAA Protected Health Information. Albany Medical Center is an equal opportunity employer.
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