Utilization Review Nurse

Department/Unit: Care Management/Social Work Work Shift: Day (United States of America) Salary Range: $71,612.39 - $110,999.20 Responsible for Utilization Management, Quality Screening and Delay Management for assigned patients. u2022 Completes Utilization Management and Quality Screening for assigned patients.u2022 Applies MCG criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Departmental standards.u2022 While performing utilization review identifies areas for clinical documentation improvement and contacts appropriate department.u2022 Identifies at-risk populations using approved screening tool and follows established reporting procedures.u2022 Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.u2022 Refers cases and issues to Medical Director and Triad Team in compliance with Department procedures and follows up as indicated.u2022 Communicates covered day reimbursement certification for assigned patients.u2022 Discusses payor criteria and issues and a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed.u2022 Uses quality screens to identify potential issues and forwards information to the Quality Department.u2022 Demonstrates proper use of MCG and documentation requirements through case review and inter-rater reliability studies.u2022 Facilitates removal of delays and documents delays when they exist. Reports internal and external delays to the Triad Team.u2022 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:u2022 Registered nurse with a New York State current license.u2022 Bachelor's degree preferred.u2022 Minimum of three years clinical experience in an assigned service.u2022 Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI andu2022 Case Management certification preferred.u2022 Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management.u2022 Self-directed with the ability to adapt in a changing environment.u2022 Basic knowledge of computer systems with skills applicable to utilization review process.u2022 Excellent written and verbal communication skills.u2022 Working knowledge of MCG criteria and ability to implement and utilize.u2022 Understanding of Inpatient versus Outpatient surgery and ICD10-Coding (preferred) and Observation status qualifications.u2022 Ability to work independently and demonstrate organizational and time management skills.u2022 Strong analytic, data management and PC skills.u2022 Working knowledge of Medicare regulatory requirements, Managed Care Plans Thank you for your interest in Albany Medical Centeru200b 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 u201cneed to knowu201d 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.

Created: 2025-12-05