RN-Utilization Rev Spec
Company: Albany Medical Center
Posted on: January 26, 2023
Case Management/Social Work
Day (United States of America)
Under direction of the Manager of Utilization Management, the
Utilization Management Specialist is responsible for the
coordination, processing and tracking of all potential utilization
concerns from the third party payors for Albany Medical Center.;
and to do other related work as required. This individual will act
as a liaison with all payors and review agents, providing required
acuity information regarding patients and issuing notice of
non-coverage as appropriate. This position is also responsible for
the processing of adverse determinations received from third party
payors, coordinating with Patient Financials Services,
Admitting/Access Operations, attending physicians, Medical Director
and AMC Case Managers and R1 Physician advisory services.
Essential Duties & Responsibilities, including but not limited
Mission, Core Values and Service Excellence: 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.
Demonstrates excellence in daily work. Actively participates in
performance and quality improvement activities and works toward
enhancing customer/patient satisfaction. 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. 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.
Contributes to a safe and secure environment for patients,
visitors, colleagues by following established procedures and
protocols, which address the needs of a diverse patient population
and workforce. 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.
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.
Strategic and Operational Planning Supports the Manager in
planning, organizing, directing of the Utilization Management
services of AMC; and to do other related work as required.
Participates in the development of departmental goals and develops
plans to achieve those goals.
Planning and Program Development Act as contact person for payors
regarding utilization issues, i.e., carve outs, denials,
downgrading and potential utilization concerns, providing required
communication regarding patient acuity. Coordination of appeal of
adverse determination, working with Service Case manager, Attending
physician, Case manager, Medical Director, R1 Physician advisory
services. for concurrent resolution of issue, prevention of
retrospective denial and delay in payment for the institution.
Maintain all correspondence and provide follow up with third party
payors, commercial insurers, and IPRO. In conjunction with the
service Case Manager, issue HINN notice and reinstatement to
patients when indicated with focus on accuracy, timeliness, and
diplomacy. Demonstrate in-depth knowledge of utilization criteria
for Medicare, Medicaid, and private insurers. Delegates and
coordinates the work of Utilization Review ASA support staff.
Tracks denials and develops action plans to decrease bad debt.
Maintain database of utilization issues and identify trends in
payor activity through generation of statistical reports. Complete
end of month reports.
Educational Leadership Working knowledge of how to research changes
in CMS and payor regulations and project impact of these changes on
AMC and communicate this information. Demonstrates proper use of
MCG and documentation requirements through case review and
inter-rate reliability studies. Attends all mandatory hospital
in-service education. Ability to analyze data and identify trends
and project expected response to changes in health care
Hospital-wide Leadership Models AMC cares standards Demonstrates
wiliness to participate in hospital wide initiatives.
Patient Safety Assists in the development of policies and
procedures, standards of care and practice, and in the monitoring
processes in relations to those standards. Maintains complete
confidentiality of patient information, in addition to hospital and
individual physician practice pattern data. Provides information
and in services as necessary to physicians and ancillary staff.
Practices in an environmentally safe and healthy manner.
+ Maintain strict adherence to the Albany Medical Center
+ Incorporate Albany Medical Center Behavioral Standards and
Guiding Principles into daily activities.
+ Comply with all Albany Medical Center Policies.
+ Comply with behavioral expectations of the department.
+ Maintain courteous and effective interactions with
+ Demonstrate an understanding of the job description, performance
expectations, and competency assessment.
+ Demonstrate a commitment toward meeting and exceeding the needs
of our customers and consistently adheres to Customer Service
+ Participate in departmental and/or interdepartmental quality
+ Participate in and successfully completes Mandatory
+ Perform all other duties as needed or directed to meet the needs
of the department.
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 CapitalRegion 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 andadministration. We value all our
staff members and offer outstanding employee benefits
+ 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 careand is home to the region's
largest hospital, only Level 1 trauma center, and only children's
hospital. Thedowntown campus also offers opportunities at Albany
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
Keywords: Albany Medical Center, Albany , RN-Utilization Rev Spec, Healthcare , Albany, New York
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