Graduate of a professional academic nursing program in which a Diploma, Associate Degree or Baccalaureate Degree is conferred. Bachelor's degree preferred. A Bachelor's Degree in a Health-related field is required.
Registered nurse with a New York State current license
A minimum of 5 years clinical experience in acute care setting with at least two years in case or utilization management.
Skills and Knowledge:
Knowledge of care delivery documentation systems and related medical record documents.
Strong broad-based clinical knowledge and understanding of pathology/physiology.
Excellent written and verbal communication skills and critical thinking skills.
Experience with Milliman MCG, InterQual criteria, and knowledge of IPRO and retrospective review process.
Ability to work independently and demonstrate organizational and time management skills.
Computer literacy and familiarity with basic office equipment and software.
Working knowledge of Medicare reimbursement system and coding structures preferred.
Essential Duties & Responsibilities , including but not limited to:
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.
Ed
Benefits
Health insurance
Additional Information
Department/Unit:
Care Management/Social Work
Work Shift:
Day (United States of America)
Salary Range:
$84,783.00 - $131,414.00
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.
Albanymed · 43 New Scotland Avenue Albany, NY 12208