Utilization Review Specialist

Pascua Yaqui Tribe•Tucson, AZ

1d•Onsite

About The Position

The Utilization Review Specialist evaluates and processes medical, dental, and optical referral requests and medical claims; approves or denies referrals and/or claims as appropriate. This role involves interviewing clients, researching information, and making appropriate decisions regarding medical services. The specialist will also provide information to clients about available health services and alternative medical resources, and manage patient registration and purchase orders within the RPMS/GUI System. Key responsibilities include verifying eligibility and benefits, documenting information, coordinating appointments and tests, and assisting with various intake processes and referrals, including those for tribal emergencies. The position may also require providing coverage for other unit functions as needed.

Requirements

High School Diploma or GED, plus one (1) year experience in a related field.
Knowledge of modern office practice.
Knowledge of customer service principles.
Knowledge of tribal community resources.
Knowledge of medical terminology and procedures.
Knowledge of Tribal/Program regulations.
Knowledge of ICD-9/10 and CPT Coding.
Knowledge of HIPAA requirements of behavioral health.
Ability to write letters/memos.
Ability to perform data entry, maintain records, and logs.
Ability to handle multiple tasks and deadlines.
Ability to use tact, courtesy and communicate well with others, orally and in writing.
Ability to prepare clear and accurate reports.
Ability to follow written and verbal instruction.
Ability to learn and apply tribal regulations and programs.
Ability to use and apply principles of managed healthcare insurance.
Ability to maintain confidentiality of information.
Ability to understand and compute payments.
Ability to operate a variety of office equipment, including a computer and related software applications.
Good communication and interpersonal skills as applied to interaction with co-workers, supervisor, management, Council members, and the public.
Sufficient ability to exchange or convey information and receive verbal and written work instructions.
Must possess and maintain a valid Arizona Driver's License.
Must have a current Level 1 Arizona Clearance Card or be able to obtain the Level 1 Arizona Clearance Card within ninety (90) days of hire.

Nice To Haves

Associate's Degree in Medical Office Administration or a Certification in Medical Office Administration is preferred, but not required.
Experience dealing with various health care providers and insurance companies, including one (1) year negotiating payments is preferred.
Knowledge of Yaqui culture, customs, resources and traditions and/or a willingness to learn.

Responsibilities

Evaluate and process medical referral requests from Maricopa County and/or Pima County; may assist in evaluating and processing dental and vision referral requests.
Evaluate medical claims, negotiate payments when appropriate and approve or deny claims.
Interview clients, when necessary, to elicit needed information.
Research information; identify relevant facts and comes to appropriate decisions.
Approve or deny referrals as appropriate.
Provide triage calls from patients or physician office when necessary.
Assist clients in person or on the phone with request for services.
Provide information to clients regarding available health services and alternative medical resources.
Input referral requests and register patients in the RPMS/GUI System; register patients into RPMS system.
Enter Contract Health Service (CHS) purchase orders known as Purchase Referred Care (PRC).
Verify eligibility and benefits prior to referral authorization for medical procedures.
Verify benefits via telephone or on the online verification systems, i.e. AHCCCS, Medicare, etc.
Contact patient via telephone and/or mail to advice of eligibility and/or benefits.
Document all eligibility/benefits in RPMS/GUI System.
Meet, as needed, with representatives from referring physician, specialty practices, and hospitals.
Complete any other practice-related projects as assigned and communicated by management.
Schedule appointments or tests as ordered by physicians.
Coordinate tests with appointments for clients when necessary.
Assist with referrals for tribal emergencies to the Office of the Treasurer.
Assist with the intake processes for dental, medical, or optical service requests.
Provide coverage for social service intakes and other areas within the unit when needed.
Perform other duties of a similar nature or level as requested by supervisor or director.