Utilization Review Nurse: Emergency Dept

Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $71,612.39 - $110,999.20 Responsibilities Utilization management and quality screening for assigned patients. Delay management, including removal of delays and documentation of delays. Apply MCG criteria to monitor appropriateness of admissions and continued stays, documenting findings based on departmental standards. Identify clinical documentation improvement opportunities and contact the appropriate department. Identify at‑risk populations using approved screening tools and follow established reporting procedures. Monitor length of stay (LOS) and ancillary resource use, taking actions to achieve continuous improvement. Refer cases and issues to the Medical Director and Triad Team in compliance with departmental procedures, and follow up as indicated. Communicate covered day reimbursement certification for assigned patients; discuss pay‑or criteria and resolve problems with payors as needed. Use quality screens to identify potential issues and forward information to the Quality Department. Demonstrate proper use of MCG and documentation requirements through case review and inter‑rater reliability studies. Collaborate with the healthcare team and appropriate departments to manage care across the continuum of care, ensuring communication with the Triad Team and the healthcare team. Maintain complete confidentiality of patient information and provide information and in‑services as necessary to physicians and ancillary staff. Core Values & Service Excellence Contribute to a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening. Recognize that each employee’s work is valuable and contributes to the success of the mission. Demonstrate excellence in daily work and actively participate in performance and quality improvement activities to enhance customer/patient satisfaction. Exhibit positive service‑excellence skills to patients, visitors, and coworkers by greeting others in a friendly manner and keeping them informed about progress, delays, and changes. Demonstrate effective teamwork by interacting positively with colleagues, fostering a collaborative environment, initiating open communication, conveying positive intent, and offering assistance. Contribute to a safe and secure environment by following established procedures and protocols. Demonstrate stewardship with responsible use of resources, maintaining a clean environment, starting work on time, and being cost‑conscious. Demonstrate respect for individual differences by acknowledging strengths, appreciating, and responding to unique backgrounds, spiritual, personal, and cultural differences. Qualifications And Ideal Characteristics Registered nurse with a New York State current license. Associate 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 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 processes. Excellent written and verbal communication skills. Working knowledge of MCG criteria and ability to implement and utilize. Understanding of inpatient versus outpatient surgery and ICD‑10 coding. Working knowledge of Medicare regulatory requirements and managed‑care plans. Observation Status Qualifications Ability to work independently and demonstrate organizational and time‑management skills. Strong analytic, data management, and PC skills. Primary Age Groups Served Infant (0–12 months) Preschool (1–4 years) School age (5–12 years) Adolescent (13–17 years) Adult (18–64 years) Older Adult (65+ years) Physical Demands Regularly required to stand, walk, use hands to probe, handle or feel items, reach with hands and arms, speak and hear. Occasionally required to sit, stoop, kneel, or crouch. Must regularly lift and/or move up to 50 pounds. Vision abilities required include close, distance, peripheral, and depth perception, and the ability to adjust focus. Work Environment The work environment may expose employees to infectious materials, chemicals, and moderate noise levels. The job requires the employee to be physically on‑site for most of the time, as remote work is not feasible. Other Requirements All job requirements listed indicate the minimum level of knowledge, skills, and/or abilities deemed necessary to perform the job proficiently. This job description is not an exhaustive statement of duties, responsibilities, or requirements. Employees may be asked to perform other job‑related instructions provided by their supervisor, subject to reasonable accommodations. Equal Opportunity 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. #J-18808-Ljbffr Albany Medical Center