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Clinical Utilization Review Specialist

2 months ago

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

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 play a critical role in ensuring the quality and efficiency of patient care.

Key Responsibilities
  • Conduct thorough utilization reviews to identify opportunities for improvement in patient care and resource utilization.
  • Collaborate with healthcare teams to develop and implement effective care plans that meet the needs of patients and reduce unnecessary costs.
  • 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 work with clinical staff to implement changes.
  • Monitor length of stay (LOS) and ancillary resource use, taking actions to achieve continuous improvement in both areas.
  • Refer cases and issues to Medical Director and Triad Team in compliance with department procedures and follow up as indicated.
  • 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. Report 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 in problem solving, critical thinking skills, 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.