Utilization Management Specialist (RN): Salary, 40hrs/week - DAYS

Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $84,783.00 - $131,414.00 Under direction of the Manager of Utilization Management, the Utilization Management Specialist is responsible for the coordination, processing, and tracking of all potential utilization concerns from third‑party payors for Albany Medical Center; and to perform other related work as required. The specialist will act as a liaison with all payors and review agents, providing required acuity information regarding patients and issuing notice of non‑coverage as appropriate. The position is also responsible for the processing of adverse determinations received from third‑party payors, coordinating with Patient Financials Services, Admitting/Access Operations, attending physicians, Medical Director, AMC Case Managers, and R1 Physician advisory services. Qualifications Graduate of a professional academic nursing program with a Diploma, Associate Degree, or Baccalaureate Degree. Bachelor’s degree preferred. Bachelor’s Degree in a Health‑related field required. Registered nurse with a New York State current license. Minimum of 5 years clinical experience in an acute care setting, with at least two years in case or utilization management. Skills and Knowledge Knowledge of care delivery documentation systems and related medical record documents. Strong broad-based clinical knowledge and understanding of pathology/physiology. Excellent written and verbal communication skills and critical thinking skills. Experience with Milliman MCG, InterQual criteria, and knowledge of IPRO and retrospective review process. Ability to work independently and demonstrate organizational and time management skills. Computer literacy and familiarity with basic office equipment and software. Working knowledge of Medicare reimbursement system and coding structures preferred. Essential Duties & Responsibilities 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 and actively participates in performance and quality improvement activities to enhance 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, which address the needs of a diverse patient population and workforce. Maintains a clean and hospitable environment, starts work on time, displays a consciousness regarding costs, supplies and departmental finances. Demonstrates respect for individual differences of each person by acknowledging the essence of each person and responding to unique spiritual, personal and cultural backgrounds. Supports the Manager in planning, organizing, directing Utilization Management services of AMC and performs related work as required. Participates in the development of departmental goals and develops plans to achieve those goals. Acts as contact person for payors regarding utilization issues (carve outs, denials, downgrading, etc.), providing required communication regarding patient acuity. Coordinates appeal of adverse determinations, working with Service Case Manager, attending physician, case manager, Medical Director, and R1 Physician advisory services for concurrent resolution. Makes sure retrospective denial and payment are prevented and mitigated. Maintains all correspondence and follows up with third‑party payors, commercial insurers, and IPRO. In conjunction with the Service Case Manager, issues HINN notice and reinstatement to patients when indicated, focusing on accuracy, timeliness, and diplomacy. Demonstrates in‑depth knowledge of utilization criteria for Medicare, Medicaid, and private insurers. Delegates and coordinates work of Utilization Review ASA support staff. Tracks denials and develops action plans to decrease bad debt. Maintains a database of utilization issues and identifies trends in payor activity through generation of statistical reports; completes end‑of‑month reports. Researches changes in CMS and payor regulations, projects impact on AMC, and communicates this information. Demonstrates proper use of MCG and documentation requirements through case review and inter‑rate reliability studies. Attends all mandatory hospital in‑service education. Analyses data and identifies trends to predict response to health care reimbursement changes. Participates in hospital‑wide initiatives and models AMC care standards. Assists in the development of policies and procedures, standards of care and practice, and monitors processes related to those standards. Maintains complete confidentiality of patient information in addition to hospital and individual physician practice pattern data. Provides information and services as necessary to physicians and ancillary staff. Practices in an environmentally safe and healthy manner. Benefits 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. 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 100 Albany Med Health System