Utilization Review Resource Specialist Jobs in Arizona

Determines qualifications for hospital level of care based on set criteria.

Initiates chart reviews, conducts follow-up reviews, and escalates secondary reviews to Physician Advisor as necessary.

Performs other duties as assigned.

Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections. (10%)

Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies. (5%)

1 year experience with medical necessity appeals

Implements and organizes downgrades compliantly and per documentation. (10%)

Identifies trends with claim holds and denials and provides communication to all necessary parties. (10%)

Communicates with all parties in a professional manner to alert of specific problem issues. (10%)

Completes pre and re-certifications for inpatient and outpatient services. Reports appropriate denial, and authorization information to designated resource.

Participates in treatment teams to ensure staff have knowledge of coverage and collects information for communication with agencies.

Works with DON to ensure documentation requirements are met.

Interfaces with managed care organizations, external reviews, and other payers.

CPR Certification and Crisis Prevention Training (CPI) preferred.

Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.