Clinical Utilization Review Specialist

5 days ago


Averill Park, 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 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.
  • Apply evidence-based criteria to determine the medical necessity of hospital admissions and continued stays.
  • Collaborate with healthcare teams to develop and implement plans of care that promote optimal patient outcomes and resource utilization.
  • Communicate with payors and other stakeholders to resolve issues and ensure timely reimbursement.
  • Participate in quality improvement initiatives to identify and address areas for improvement in clinical documentation and resource utilization.
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.


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