Utilization Review Nurse Position Available In Albany, New York

Job Description:

Ravena, NY, United States Department/Unit:

CareManagement/Social Work Work Shift:

Day (United States of America)

Salary Range:

$71,612.39 – $110,999.20 Responsible for UtilizationManagement, Quality Screening and Delay Management for assignedpatients.

• Completes Utilization Management and Quality Screeningfor assigned patients.
• Applies MCG criteria to monitorappropriateness of admissions and continued stays, and documentsfindings based on Departmental standards.
• While performingutilization review identifies areas for clinical documentationimprovement and contacts appropriate department.
• Identifiesat-risk populations using approved screening tool and followsestablished reporting procedures.
• Monitors LOS and ancillaryresource use on an ongoing basis. Takes actions to achievecontinuous improvement in both areas.
• Refers cases and issues toMedical Director and Triad Team in compliance with Departmentprocedures and follows up as indicated.
• Communicates covered dayreimbursement certification for assigned patients.
• Discussespayor criteria and issues and a case-by-case basis with clinicalstaff and follows up to resolve problems with payors as needed.
• Uses quality screens to identify potential issues and forwardsinformation to the Quality Department.
• Demonstrates proper use ofMCG and documentation requirements through case review andinter-rater reliability studies.
• Facilitates removal of delaysand documents delays when they exist. Reports internal and externaldelays to the Triad Team.
• Collaborates with the health care teamand appropriate department in the management of care across thecontinuum of care by assuring communication with Triad Team andhealth care team.

Minimum Qualifications:

• Registered nurse with aNew York State current license.
• Bachelor’s degree preferred.
• Minimum of three years clinical experience in an assigned service.
• Recent experience in case management, utilization managementand/or discharge planning/home care in a high volume, acute carehospital preferred. PRI and
• Case Management certificationpreferred.
• Assertive and creative in problem solving, criticalthinking 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 toutilization review process.
• Excellent written and verbalcommunication skills.
• Working knowledge of MCG criteria andability to implement and utilize.
• Understanding of Inpatientversus Outpatient surgery and ICD10-Coding (preferred) andObservation status qualifications.
• Ability to work independentlyand demonstrate organizational and time management skills.
• Stronganalytic, data management and PC skills.
• Working knowledge ofMedicare regulatory requirements, Managed Care Plans Thank you foryour interest in Albany Medical Center!

? Albany Medical is an equalopportunity employer. This role may require access to informationconsidered sensitive to Albany Medical Center, its patients,affiliates, and partners, including but not limited to HIPAAProtected Health Information and other information regulated byFederal and New York State statutes. Workforce members are expectedto 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 ofinformation needed to accomplish an intended purpose. Reasonableefforts, consistent with Albany Med Center policies and standards,shall be made to ensure that information is adequately protectedfrom unauthorized access and modification.