Utilization Review Case Manager Jobs in Apache Junction, AZ

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https://hr.uky.edu/employment/working-uk/equivalencies

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Responsible for supporting utilization review processes to ensure accurate documentation, timely processing, and compliance with payer and regulatory requirements. Provides advanced technical support to utilization management teams by reviewing records for completeness, verifying data accuracy, and preparing information for clinical review. Ensures consistency in documentation, reporting, and workflow management to reduce errors and improve efficiency. Coordinates with nurses, case managers, and revenue cycle staff to facilitate utilization review operations and support denial prevention. Develops reports, monitors trends, and assists in quality assurance activities to strengthen compliance and operational performance.

Reviews patient records for completeness and accuracy to support clinical utilization review activities.

Utilize EMR Case Management work queues and reports for new admission or insurance update without payer notification, denials pending appeal and retro eligible Medicaid activities.

Prepares and submits required documentation to payers for authorizations, continued stay requests, discharge dates and discharge summaries under RN guidance.

Ensures timely and accurate entry of utilization review data into electronic health record and case management systems.

Monitors payer portals, process incoming faxes, answer phone calls and communicate approval, denials or record requests to clinical staff as needed.

Identifies workflow issues and recommends improvements to enhance accuracy and efficiency.

Collaborates with revenue cycle, compliance, and case management teams to support denial prevention and audit readiness.

Independently resolves internal and external reasons for payer authorization and appeal response delays.

Provides guidance and mentoring to junior utilization review support staff.

Performs other duties as assigned.

Education Requirement: High school diploma or equivalent

Experience Requirement: 3-5 years of experience

An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated based on hours worked per week. Volunteer work and internships for academic credit are not counted.

Certifications & Licensures: N/A

A. Lifting, pushing, and/or pulling objects up to 50lbs:1. Never

B. Lifting, pushing, and/or pulling objects over 50lbs:1. Never

C. Standing or walking with objects up to 10lbs:3. Intermittent (10% - 50% of the time)

D. Standing or walking with objects up to 25lbs:1. Never

E. Sitting at the computer workstation for extended periods:3. Regular (90% - 100% of the time)

F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials:1. Never

G. Repetitive motion:3. Intermittent (10% - 50% of the time)

H. Working at heights above 4 feet:1. Never

I. Working in confined spaces:1. Never

J. Risk of injuries from use of equipment on the job:2. Occasional (< 10% of the time)

K. Job-related travel:1. Never

L. Loud noises:1. Never

M. Temperature extremes:1. Never

N. Hazardous chemicals and fumes including waste:1. Never

O. Radiation:1. Never

P. Burns:1. Never

Q. Cuts/Punctures:1. Never

R. Bloodborne/airborne pathogens:1. Never

S. Recombinant DNA or viral vectors:1. Never

T. Combative/violent people:1. Never

U. Animal handling (including carcasses):1. Never

V. Please specify other(s) and amount of exposure (i.e. Occasional, Intermittent or Regular): N/A

This position requires sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); intermittent standing or walking with objects weighing up to 10 pounds.

Our University Community

We value the well-being of each of our employees and are dedicated to creating a healthy place for everyone to work, learn and live. In the interest of maintaining a safe and healthy environment for our students, employees, patients and visitors, the University of Kentucky is a Tobacco & Drug Free campus.

The University follows both the federal and state Constitutions as well as all applicable federal and state laws on nondiscrimination. The University provides equal opportunities for qualified persons in all aspects of institutional operations and does not discriminate on the basis of race, color, national origin, ethnic origin, religion, creed, age, physical or mental disability, veteran status, uniformed service, political belief, sex, sexual orientation, gender identity, gender expression, pregnancy, marital status, genetic information or social or economic status.

Any candidate offered a position may be required to pass pre-employment screenings as mandated by University of Kentucky Human Resources. These screenings may include a national background check and/or drug screen.