Job Description

Albany Medical Center is seeking a passionate and skilled Utilization Review Registered Nurse to join our Care Management/Social Work Department. This is a daytime position based in Malden Bridge, NY. As a Utilization Review Nurse, you will play a critical role in ensuring optimal patient care through effective Utilization Management, Quality Screening, and Delay Management for assigned patients. Your responsibilities will include: Conducting Utilization Management and Quality Screening for assigned patients. Applying MCG criteria to monitor appropriateness of admissions and continued stays, documenting findings according to departmental standards. Identifying opportunities for clinical documentation improvement and collaborating with relevant departments. Monitoring length of stay (LOS) and resource utilization, taking action to promote continuous improvement. Referring complex cases and issues to the Medical Director and Triad Team in accordance with departmental procedures, and following up as needed. Communicating covered day reimbursement certification for assigned patients. Discussing payor criteria and issues with clinical staff and resolving problems with payors as necessary. Using quality screens to identify potential issues and forwarding findings to the Quality Department. Facilitating the removal of delays in patient care and documenting delays as they occur. Collaborating with the healthcare team to ensure effective care management throughout the continuum of care. Minimum Qualifications: Current Registered Nurse license in New York State. Bachelor's degree preferred. A minimum of three years of 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 is preferred. Preferably holds a PRI and Case Management certification. Strong problem-solving abilities along with critical thinking and patient care management skills. Self-directed and adaptable to a changing environment. Basic computer skills related to the utilization review process. Excellent written and verbal communication abilities. Working knowledge of MCG criteria and the ability to implement and utilize effectively. Understanding of Inpatient vs. Outpatient surgery and ICD-10 coding is preferred. Capability to work independently with strong organizational and time management skills. Analytical skills with experience in data management and PC proficiency. Familiarity with Medicare regulatory requirements and Managed Care Plans. Join our team at Albany Medical Center and contribute to improving patient care through comprehensive utilization management efforts. We are an equal opportunity employer and value diversity within our workforce. This role involves access to sensitive information, including HIPAA Protected Health Information. Workforce members are required to handle information based on a need-to-know basis and adhere to Albany Medical Center policies regarding confidentiality and data protection. Albany Medical Center

Job Tags

Similar Jobs