Utilization Review Specialist

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.

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

Knowledge of:

• Modern office practice;
• Customer service principles;
• Tribal community resources;
• Medical terminology and procedures;
• Tribal/Program regulations;
• ICD-9/10 and CPT Coding;
• HIPAA requirements of behavioral health;
• Yaqui culture, customs, resources and traditions and/or a willingness to learn.

• Write letters/memos;
• Data entry, maintain records, and logs;
• Handle multiple tasks and deadlines;
• Use tact, courtesy and communicate well with others, orally and in writing;
• Prepare clear and accurate reports;
• Follow written and verbal instruction;
• Learn and apply tribal regulations and programs;
• Use and apply principals of managed healthcare insurance;
• Maintain confidentiality of information;
• Understand and compute payments;
• 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. Have ability to sufficiently exchange or convey information and receive verbal and written work instructions.

High School Diploma or GED, plus one (1) year experience in a related field.

• 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.

• Must possess and maintain a valid Arizona Driver's License;
• This position will require the incumbent to work non-traditional hours, nights, and weekends;
• 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. Failure to maintain a current Level 1 Clearance Card will result in termination.