Clinical Utilization Review Specialist

We are seeking a skilled Clinical Utilization Review Specialist to join our team at Albany Medical Center. As a key member of our Care Management 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.
• Collaborate with healthcare teams to develop and implement effective care plans that meet the needs of patients and families.
• Apply MCG criteria to monitor the appropriateness of admissions and continued stays, and document findings in accordance with departmental standards.
• Identify areas for clinical documentation improvement and work with clinical staff to implement changes.
• Monitor length of stay and ancillary resource use, and take actions to achieve continuous improvement in both areas.
• Refer cases and issues to the Medical Director and Triad Team as needed, and follow up to ensure resolution.
• Communicate covered day reimbursement certification for assigned patients, and discuss payor criteria and issues on a case-by-case basis with clinical staff.
• Use quality screens to identify potential issues and forward information to the Quality Department.
• Facilitate removal of delays and document delays when they exist, and 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.

Albany Medical Center is an equal opportunity employer and offers a competitive salary and benefits package.

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.