Utilization Review Nurse - Care Management Specialist

We are seeking a skilled Utilization Review Nurse to join our Care Management team at Albany Medical Center. As a key member of our team, you will be responsible for ensuring the efficient and effective use of healthcare resources while maintaining high-quality 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 patient needs and optimize resource allocation.
• Apply MCG criteria to monitor appropriateness of admissions and continued stays, and document findings according to departmental standards.
• Identify areas for clinical documentation improvement and work with the team to implement changes.
• Monitor length of stay (LOS) and ancillary resource use, taking actions to achieve continuous improvement.
• Communicate with payors and clinical staff to resolve issues and ensure seamless care transitions.
• 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. 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.