Utilization Review Nurse

100 Albany Med Health System; City of Albany (NY); On-site; USD 77,000 - 119,000; Full time

Job summary

Albany Med Health System is seeking a registered nurse to join Care Management/Social Work in the day shift. The role focuses on utilization management, applying MCG criteria, and coordinating care across the continuum.

Requirements include NY RN license, an associate degree (bachelor's preferred), and at least three years of clinical experience. PRI/Case Mgmt certification preferred; strong communication, analytical, and documentation skills are essential.

Qualifications

• RN licensed in New York State.
• Associate's degree required; Bachelor's preferred.
• Minimum of three years clinical experience in an assigned service.
• PRI and Case Management certification preferred.
• Strong problem solving, critical thinking and communication skills.
• Self-directed with adaptability in changing environment.
• Proficient with computer systems and utilization review processes.
• Knowledge of inpatient vs outpatient surgery and documentation requirements.

Responsibilities

• Completes Utilization Management and Quality Screening for assigned patients.
• Applies MCG criteria to monitor admissions and continued stays; documents findings.
• Identifies areas for clinical documentation improvement and communicates with the appropriate department.
• Identifies at-risk populations using approved screening tools and follows reporting procedures.
• Monitors length of stay and ancillary resource use; works to improve both.
• Refers cases to Medical Director and Triad Team; follows up as indicated.
• Communicates covered day reimbursement certification for assigned patients.
• Discusses payor criteria with clinical staff and resolves payor issues as needed.
• Uses quality screens to identify issues and forwards information to Quality Department.
• Demonstrates proper use of MCG criteria and documentation; participates in reliability studies.
• Facilitates removal of delays; reports delays to Triad Team.
• Collaborates with health care team to manage care across the continuum.

Skills

RN license

Case management

Utilization review

Discharge planning

Communication skills

Critical thinking

Analytical skills

Microsoft Office

Education

Associate's degree

Bachelor's degree

Tools

MCG criteria knowledge

ICD-10 coding understanding

Medicare regulatory knowledge

Job description

Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $77,075.00 - $119,466.00

Responsibilities

• 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.
• 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.

Minimum Qualifications

• 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

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.

Albany Medical Center is the centerpiece of medicine, research, and medical education in New York's Capital Region and is the area's largest private employer with more than 10,000 employees. Albany Medical Center offers excellent career opportunities in a wide range of roles in both patient care and administration. We value all our staff members and offer outstanding employee benefits including:

• Excellent health care coverage with no copay at Albany Medical Center providers
• A wide array of services and programs to support emotional, physical, and mental wellbeing

The downtown campus also offers opportunities at Albany Medical College. Albany Medical Center, along with Columbia Memorial Health, Glens Falls Hospital, Saratoga Hospital, and the Visiting Nurses, form the Albany Med Health System, serving more than three million people over 25 counties.