Clinical Utilization Review Specialist
2 weeks 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 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.
- 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.
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Ravena, New York, United States Albany Medical Center Full time{"Job Title": "Clinical Utilization Specialist", "Job Summary": "We are seeking a skilled Clinical Utilization Specialist to join our team at Albany Medical Center. In this role, you will be responsible for ensuring the efficient and effective use of healthcare resources while maintaining high-quality patient care.Responsibilities:* Conduct thorough reviews...
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