Utilization Review Nurse

Department/Unit:
Care Management/Social Work

Work Shift:
Day (United States of America)

Salary Range:
$77,075.00 - $119,466.00

Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients.

• 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.