Clinical Utilization Review Nurse

We are seeking a dedicated Clinical Utilization Review Nurse to join our Care Management/Social Work Department. This role is essential in optimizing patient care through effective Utilization Management, Quality Screening, and Delay Management.

Location: Altamont, NY, United States

Work Shift: Day

Salary Range: $71,612.39 - $110,999.20

Key Responsibilities:

Conduct comprehensive Utilization Management and Quality Screening for assigned patients, ensuring all findings are documented in line with Department standards.

Apply MCG criteria to monitor the appropriateness of admissions and continued stays.

Identify and report areas for clinical documentation improvement while collaborating closely with relevant departments.

Utilize approved screening tools to identify at-risk populations and adhere to established reporting protocols.

Continuously monitor Length of Stay (LOS) and ancillary resource usage, striving for ongoing improvement.

Refer critical cases and issues to the Medical Director and Triad Team, ensuring proper follow-up as per Department procedures.

Communicate reimbursement certifications for assigned patients and address payor criteria issues with the clinical staff.

Utilize quality screens to detect potential issues, forwarding insights to the Quality Department.

Document and report any delays in patient care to facilitate timely resolutions.

Work collaboratively with healthcare teams to ensure effective care management across all stages of patient care.

Qualifications:

Active RN license in New York State.

Bachelor's degree in nursing preferred.

A minimum of three years of clinical experience in your designated service area.

Preferred experience in case management, utilization management, or discharge planning within a high-volume acute care hospital.

Certifications in PRI and Case Management are advantageous.

Demonstrated critical thinking, problem-solving abilities, and effective patient care management skills.

Ability to thrive in a fast-paced, evolving healthcare environment.

Proficient with technology, including basic computer systems relevant to utilization review.

Exceptional written and verbal communication skills.

Familiar with MCG criteria and skilled in their implementation.

Understanding of inpatient versus outpatient surgery classifications, ICD-10 coding, and observation status qualifications is preferred.

Adept at working independently with strong organizational and time management skills.

Experience in data management and a solid grasp of Medicare regulatory requirements and Managed Care Plans.

Thank you for considering a career with Albany Medical Center. We are proud to be an equal opportunity employer.

This position may require access to sensitive information, including HIPAA Protected Health Information. Workforce members are expected to protect this information in accordance with Albany Medical Center's policies and standards.