Job Summary:

The Utilization Review/Quality Assurance Sr. Coordinator will be responsible for providing clinical information to managed care companies as requested for hospitalized patients both concurrently and retrospectively per hospital policy and procedure to prevent denial of payment. Will assist/participate in special utilization studies/projects and the development of new programs/processes. Responsible for working with the Case Management to ensure the appropriate application of Interqual Criteria at the time of admission and for continued stay and processing level of care changes. Responsible for issuing notices of non-coverage per hospital policy and procedure and for taking the lead in the discharge appeal process. Reviews high-cost outlier accounts for appropriate charges, rounds with the interdisciplinary teams, and attends committee meetings as requested. Works closely with Clinical Data and Finance staff and must maintain current knowledge of federal regulations and all CMS activities.

Minimum Qualifications:

NYS Licensed/Registered (or eligible) RN, Bachelors Degree in Nursing (or healthcare-related field) and a minimum of three years RN post-licensure nursing experience or RN Utilization Management, or Associate's Degree in Nursing and five years RN post-licensure nursing experience required. Excellent communication and customer service skills are required to interface with healthcare payers, regulatory agencies, and other health care related entities.     

Preferred Qualifications:

Utilization Review/Managed Care/Quality Assurance experience. Experience in the application of InterQual Adult and Pediatric Acute Care Screening Criteria. Experience interfacing with health care payers/regulatory agencies.

Work Days:

Monday through Friday 8 am-4:30 pm with occasional weekends and evenings

Message to Applicants:

This position is primarily remote with some onsite responsibilities.  Position was originally posted on Dec 9th, 2024 and refreshed on 3/3/2025.

Recruitment Office: Human Resources

Executive Order:

Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor's Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov.