Utilization Review Nurse

Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. Salary: $65,062.40 - $107,348.80 • 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. Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, 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 Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Albany Med is the centerpiece of medicine, research, and medical education in New York’s Capital Region and is the area's largest private employer with more than 10,000 employees. Albany Med offers excellent career opportunities in a wide range of roles in both patient care and administration. We value all our staff members and offer outstanding employee benefits including: Excellent health care coverage with lower copays at most Albany Med providers. A wide array of services and programs to support emotional, physical, and mental wellbeing Anchored in the state’s historic capital city, Albany Med offers a full range outpatient and inpatient care and is home to the region’s largest hospital, only Level 1 trauma center, and only children’s hospital. The downtown campus also offers opportunities at Albany Medical College. Albany Med partners with Columbia Memorial Health, Saratoga Hospital and Glens Falls Hospital to form the Albany Med Health System, serving more than three million people over 25 counties.