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Utilization Management Specialist – RN
| Company | Albany Medical College |
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| Location | Albany, NY, USA |
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| Salary | $78773.63 – $122099.12 |
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| Type | Full-Time |
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| Degrees | Bachelor’s |
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| Experience Level | Senior |
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Requirements
- 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.
- 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.
Responsibilities
- Coordinate, process and track all potential utilization concerns from third party payors for Albany Medical Center.
- Act as a liaison with all payors and review agents, providing required acuity information regarding patients and issuing notice of non-coverage as appropriate.
- Process 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.
- Support the Manager in planning, organizing, directing of the Utilization Management services of AMC.
- Participate in the development of departmental goals and develop plans to achieve those goals.
- Act as contact person for payors regarding utilization issues, providing required communication regarding patient acuity.
- Coordinate appeal of adverse determination, working with Service Case manager, Attending physician, Case manager, Medical Director, R1 Physician advisory services for concurrent resolution of issue.
- Maintain all correspondence and provide follow up with third party payors, commercial insurers, and IPRO.
- Track denials and develop 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.
- Assist in the development of policies and procedures, standards of care and practice, and in the monitoring processes in relations to those standards.
Preferred Qualifications
- Working knowledge of Medicare reimbursement system and coding structures preferred.
