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 quality and appropriateness 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 these areas.
• Communicate with payors and resolve issues related to coverage and reimbursement.
• Use quality screens to identify potential issues and forward information to the Quality Department.

• 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.