Utilization Review Nurse
Company: Albany Medical Center
Location: Albany
Posted on: January 25, 2023
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Job Description:
43 New Scotland Avenue Albany, NY 12208
Department/Unit:Case Management/Social WorkWork Shift:Day (United
States of America)The Position
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. Bachelor's degree required. Masters 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
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.
Keywords: Albany Medical Center, Albany , Utilization Review Nurse, Healthcare , Albany, New York
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