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.

Qualifications and Ideal Characteristics

1. Registered nurse with a New York State current license.

2. Associate's degree required. Bachelor's degree preferred.

3. Minimum of three years clinical experience in an assigned service.

4. 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.

5. Assertive and creative in problem solving, critical thinking skills, systems planning

and patient care management.

6. Self-directed with the ability to adapt in a changing environment.

7. Basic knowledge of computer systems with skills applicable to utilization review

process.

8. Excellent written and verbal communication skills.

9. Working knowledge of MCG criteria and ability to implement and utilize.

10. Understanding of Inpatient versus Outpatient surgery and ICD10-Coding

(preferred) and Observation status qualifications.

11. Ability to work independently and demonstrate organizational and time

management skills.

12. Strong analytic, data management and PC skills.

13. Working knowledge of Medicare regulatory requirements, Managed Care Plans

Principal Position Responsibilities

A. Mission, Core Values and Service Excellence

1. 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.

2. Demonstrates excellence in daily work. Willing to actively participate in

performance and quality improvement activities and to work towards enhancing

customer/patient satisfaction.

3. 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.

4. 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.

5. Contributes to a safe and secure environment for patients, visitors, colleagues by

following established procedures and protocols.

6. Demonstrates stewardship by thoughtful and responsible use of resources

including maintaining a clean and hospitable environment, starting work on time,

displaying a consciousness regarding costs, supplies and department finances.

7. Demonstrates respect for individual differences of each person by

acknowledging the essence of each person, appreciating, and responding to

unique, spiritual, personal, and cultural backgrounds of patients, families, and

colleagues.

B. Utilization Management

1. Completes Utilization Management and Quality Screening for assigned patients.

2. Applies MCG criteria to monitor appropriateness of admissions and continued

stays, and documents findings based on Departmental standards.

3. While performing utilization review identifies areas for clinical documentation

improvement and contacts appropriate department.

4. Identifies at-risk populations using approved screening tool and follows

established reporting procedures.

5. Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to

achieve continuous improvement in both areas.

6. Refers cases and issues to Medical Director and Triad Team in compliance with

Department procedures and follows up as indicated.

7. 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.

8. Uses quality screens to identify potential issues and forwards information to the

Quality Department.

9. Demonstrates proper use of MCG and documentation requirements through case

review and inter-rater reliability studies.

10. Delay Management

11. Facilitates removal of delays and documents delays when they exist. Reports

internal and external delays to the Triad Team.

12. 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.

13. Maintains complete confidentiality of patient information, in addition to hospital

and individual physician practice pattern data. Provides information and inservices

as necessary to physicians and ancillary staff.

Primary Age Groups Served

___ Infant (0-12 months) ___ Preschool (1-4 yrs) ___ School age (5-12 yrs)

___ Adolescent (13-17 yrs) ___ Adult (18-64 yrs) ___ Older Adult (65 + yrs)

Physical Demands:

The physical demands described here are representative of those that must be met by an

employee to successfully perform the essential functions of this job. While performing the

duties of this job, the employee is regularly required to stand, walk, use hands to probe,

handle, or feel objects, tools, or controls, reach with hands and arms, and speak and hear.

The employee is occasionally required to sit and stoop, kneel, or crouch.

The employee must regularly lift and/or move up to 50 pounds. Specific vision abilities

required by this job include close vision, distance vision, peripheral vision, depth perception,

and the ability to adjust focus.

Work Environment:

The work environment characteristics described here are representative of those an

employee encounters while performing the essential functions of this job. While performing

the duties of this job, the employee may be subject to infectious materials and chemicals

(see unit specific MSDS information). The noise level in the work environment is usually

moderate. This job requires as an essential function that the majority of the time the

employee be physically on-site as the work cannot be done from a remote location.

Other Requirements:

All job requirements listed indicate the minimum level of knowledge, skills, and/or ability

deemed necessary to perform the job proficiently. This job description is not to be construed

as an exhaustive statement of duties, responsibilities, or requirements. Employees will be

required to perform any other job-related instructions given by their supervisor subject to

reasonable accommodations.

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.