Clinical Utilization Review Specialist

We are seeking a skilled Utilization Review Nurse to join our team at Albany Medical Center. As a key member of our Care Management/Social Work department, you will play a critical role in ensuring the efficient and effective delivery of patient care.

• Conduct thorough utilization reviews to identify opportunities for improvement in patient care and resource utilization.
• Apply MCG criteria to monitor the appropriateness of admissions and continued stays, and document findings in accordance with departmental standards.
• Collaborate with healthcare teams to identify areas for clinical documentation improvement and implement changes as needed.
• Utilize approved screening tools to identify at-risk populations and develop strategies for improvement.
• Monitor length of stay (LOS) and ancillary resource use, taking proactive steps to achieve continuous improvement.
• Communicate with payors to resolve issues and ensure timely reimbursement.
• Facilitate the removal of delays and document delays when they exist, reporting to the Triad Team as needed.

• 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, with the ability to adapt in a changing environment.
• Basic knowledge of computer systems and 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 sensitive information, and workforce members are expected to ensure that access is based on a 'need to know' and is the minimum necessary to properly perform assigned duties.