Clinical Utilization Review Nurse

Albany Medical Center is seeking a dedicated Clinical Utilization Review Nurse to join our Care Management/Social Work team. This role focuses on ensuring quality patient care while managing utilization effectively.

As a Clinical Utilization Review Nurse, you will be responsible for the following:

Conducting Utilization Management and Quality Screening for assigned patients.

Applying MCG criteria to assess the appropriateness of admissions and continuous stays while documenting findings in accordance with departmental standards.

Identifying opportunities for clinical documentation improvement and collaborating with the relevant departments.

Utilizing approved screening tools to monitor at-risk populations and adhering to established reporting procedures.

Monitoring Length of Stay (LOS) and ancillary resource utilization continuously to foster ongoing improvement.

Referring cases and issues to the Medical Director and Triad Team per departmental procedures and ensuring proper follow-up.

Communicating covered day reimbursement certification for assigned patients.

Engaging with clinical staff on payer criteria and issues on a case-by-case basis to address and resolve challenges with payers.

Employing quality screens to identify potential issues and forwarding information to the Quality Department.

Facilitating the resolution of care delays and documenting any that occur, reporting effectively to the Triad Team.

Collaborating with healthcare teams to manage patient care across the continuum, ensuring clear communication with all involved parties.

Minimum Qualifications:

Current Registered Nurse license in New York State.

Bachelor's degree preferred.

A minimum of three years of clinical experience in a relevant service area.

Recent experience in case management, utilization management, or discharge planning/home care within a high-volume acute care hospital is preferred.

PRI and Case Management certifications are a plus.

Possessing strong problem-solving abilities, critical thinking skills, and proficiency in systems planning and patient care management.

Ability to navigate a dynamic environment self-directed.

Basic computer skills relevant to the utilization review process are necessary.

Excellent written and verbal communication abilities are required.

Familiarity with MCG criteria and adeptness in applying and using it.

Understanding of Inpatient vs. Outpatient surgery and ICD10-Coding qualifications (preferred).

Capacity to work independently while showcasing robust organizational and time management skills.

Strong analytical, data management, and PC capabilities are essential.

Knowledge of Medicare regulatory requirements and Managed Care Plans is preferred.

If you are passionate about improving patient outcomes and have the qualifications we seek, we encourage you to apply to be part of our team.

Thank you for your interest in Albany Medical Center!

Albany Medical Center is an equal opportunity employer.

This position may require access to sensitive information in accordance with HIPAA and other regulations. Employees must ensure access is based on the need to know and adheres to minimum necessary standards to protect information from unauthorized access and modification.