Utilization Review Nurse

Albany Medical Center; City of Albany (NY); On-site; USD 77,000 - 119,000; Full time

Job summary

Albany Med Health System is seeking a Registered Nurse in Care Management/Social Work to lead Utilization Management, Quality Screening and Delay Management for assigned patients in a high-volume acute care setting. Requires NYS RN license, Associate degree (Bachelor's preferred), and at least 3 years of clinical experience with case management or discharge planning.

Familiarity with MCG criteria, Medicare rules, strong communication, analytical and data management skills is preferred; on-site,

Qualifications

• RN license in New York State
• Associate degree required; Bachelor’s degree preferred
• Minimum of three years clinical experience in an assigned service
• Experience in case management, utilization management and/or discharge planning/home care in a high-volume acute care hospital preferred

Responsibilities

• Mission, Core Values and Service Excellence
• Contributes to compassionate environment for patients, families and colleagues
• Exhibits service excellence by greeting others, keeping stakeholders informed
• Utilization Management: completes reviews, applies MCG criteria, documents findings
• Delay Management: facilitates removal of delays and reports them to Triad Team

Skills

Communication skills

Problem solving

Teamwork

Self-directed

Analytical skills

Time management

Education

Associate's degree

Bachelor's degree preferred

Tools

MCG criteria knowledge

Medicare regulatory knowledge

PC skills

Job description

Department/Unit:
Care Management/Social Work
Work Shift:
Day (United States of America)
Salary Range:
$77,075.00 - $119,466.00
Responsible for Utilization Management, Quality Screening and Delay Management for
assigned patients.

Qualifications And Ideal Characteristics

• Registered nurse with a New York State current license.
• Associate's degree required. 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. PRI and

Case Management certification preferred.

• Assertive and creative in problem solving, critical thinking skills, 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
  

Principal Position Responsibilities

• Mission, Core Values and Service Excellence
• Contributes to the creation of a compassionate and caring environment for
  

patients, families, and colleagues through displays of kindness and active
listening. Recognizes and appreciates that each employee’s work is valuable
and contributes to the success of the Mission.

• Demonstrates excellence in daily work. Willing to actively participate in
  

performance and quality improvement activities and to work towards enhancing
customer/patient satisfaction.

• Exhibits positive service excellence skills to patients, visitors, and coworkers by
  

greeting others in a friendly manner, keeping customers/patients/colleagues
informed about progress, delays, and changes.

• Demonstrates effective teamwork by interacting in a positive manner with
  

colleagues and creating a collaborative work environment. Initiates open
communication, conveys positive intent, offers assistance.

• Contributes to a safe and secure environment for patients, visitors, colleagues by
  

following established procedures and protocols.

• Demonstrates stewardship by thoughtful and responsible use of resources
  

including maintaining a clean and hospitable environment, starting work on time,
displaying a consciousness regarding costs, supplies and department finances.

• Demonstrates respect for individual differences of each person by
  

acknowledging the essence of each person, appreciating, and responding to
unique, spiritual, personal, and cultural backgrounds of patients, families, and
colleagues.

• Utilization Management
• Completes Utilization Management and Quality Screening for assigned patients.
• Applies MCG criteria to monitor appropriateness of admissions and continued
  

stays, and documents findings based on Departmental standards.

• While performing utilization review identifies areas for clinical documentation
  

improvement and contacts appropriate department.

• Identifies at-risk populations using approved screening tool and follows
  

established reporting procedures.

• Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to
  

achieve continuous improvement in both areas.

• Refers cases and issues to Medical Director and Triad Team in compliance with
  

Department procedures and follows up as indicated.

• Communicates covered day reimbursement certification for assigned patients.
  

Discusses payor criteria and issues and a case-by-case basis with clinical staff
and follows up to resolve problems with payors as needed.

• Uses quality screens to identify potential issues and forwards information to the
  

Quality Department.

• Demonstrates proper use of MCG and documentation requirements through case
  

review and inter-rater reliability studies.

• Delay Management
• Facilitates removal of delays and documents delays when they exist. Reports
  

internal and external delays to the Triad Team.

• Collaborates with the health care team and appropriate department in the
  

management of care across the continuum of care by assuring communication
with Triad Team and health care team.

• Maintains complete confidentiality of patient information, in addition to hospital
  

and individual physician practice pattern data. Provides information and inservices
as necessary to physicians and ancillary staff.

Primary Age Groups Served
___ Infant (0-12 months) ___ Preschool (1-4 yrs) ___ School age (5-12 yrs)
___ Adolescent (13-17 yrs) ___ Adult (18-64 yrs) ___ Older Adult (65 + yrs)

Physical Demands

The physical demands described here are representative of those that must be met by an
employee to successfully perform the essential functions of this job. While performing the
duties of this job, the employee is regularly required to stand, walk, use hands to probe,
handle, or feel objects, tools, or controls, reach with hands and arms, and speak and hear.
The employee is occasionally required to sit and stoop, kneel, or crouch.
The employee must regularly lift and/or move up to 50 pounds. Specific vision abilities
required by this job include close vision, distance vision, peripheral vision, depth perception,
and the ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an
employee encounters while performing the essential functions of this job. While performing
the duties of this job, the employee may be subject to infectious materials and chemicals
(see unit specific MSDS information). The noise level in the work environment is usually
moderate. This job requires as an essential function that the majority of the time the
employee be physically on-site as the work cannot be done from a remote location.

Other Requirements

All job requirements listed indicate the minimum level of knowledge, skills, and/or ability
deemed necessary to perform the job proficiently. This job description is not to be construed
as an exhaustive statement of duties, responsibilities, or requirements. Employees will be
required to perform any other job-related instructions given by their supervisor subject to
reasonable accommodations.

Thank you for your interest in Albany Med Health System!
Albany Med Health System is an equal opportunity employer.
This role may require access to information considered sensitive to Albany Med Health System, 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. Workforce members are expected to ensure that:
Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.