Utilization Review Nurse Specialist

2 weeks ago

North Chatham, 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. As a Utilization Review Nurse, you will play a critical role in ensuring that patients receive the most appropriate care while minimizing unnecessary costs.

Key Responsibilities:
  • Conduct thorough reviews of patient records to identify areas for improvement in care and resource utilization.
  • Apply MCG criteria to monitor the appropriateness of admissions and continued stays, and document findings according to departmental standards.
  • Identify at-risk populations using approved screening tools and follow established reporting procedures.
  • Collaborate with the healthcare team to develop and implement plans to improve patient outcomes and reduce costs.
  • Communicate with payors and other stakeholders to resolve issues and ensure seamless care transitions.
  • Stay up-to-date with changing regulations and guidelines to ensure compliance and optimal care delivery.
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.
  • 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.

Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes.

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. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

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