Utilization Management Specialist; RN

Department/Unit

Care Management/Social Work

Day (United States of America)

$84,783.00 - $

Under direction of the Manager of Utilization Management, the Utilization Management Specialist is responsible for coordination, processing and tracking of all potential utilization concerns from third party payors for Albany Medical Center. The role acts as a liaison with payors and review agents, providing required acuity information regarding patients and issuing notice of non‑coverage as appropriate. This position also processes adverse determinations from third party payors, coordinating with Patient Financials Services, Admitting/Access Operations, attending physicians, Medical Director, AMC Case Managers and R1 Physician advisory services.

• Graduate of a professional academic nursing program with a Diploma, Associate Degree or Baccalaureate Degree. Bachelor’s degree preferred. A Bachelor’s Degree in a Health‑related field is required.
• Registered nurse with a New York State current license.
• Minimum of 5 years clinical experience in an 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, Inter Qual 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.

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:
Acts 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.

Mainta…