Utilization Review Rn Jobs in San Tan Valley, AZ

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Equivalency Link

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

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Responsible for supervising daily operations of the utilization review team to ensure compliance with regulatory requirements, payer guidelines, and organizational standards. Provides oversight of utilization management processes to support appropriate levels of care, efficient resource use, and timely authorization determinations. Ensures accurate clinical documentation, promotes adherence to medical necessity criteria, and develops staff to achieve performance and quality goals. Coordinates with physicians, payers, and interdisciplinary teams to support effective patient care management and optimal reimbursement.

Supervises daily activities of utilization review staff, including scheduling, assignments, and workload distribution.

Reviews and monitors utilization review cases for accuracy, completeness, and compliance with payer and regulatory requirements.

Provides coaching, training, and performance feedback to utilization review team members.

Develops and implements quality assurance processes to ensure adherence to medical necessity criteria and organizational standards.

Collaborates with physicians, case managers, and payers to resolve complex authorization and medical necessity issues.

Prepares and presents utilization review reports and metrics to management, highlighting trends and opportunities for improvement.

Assists in policy and procedure development to support compliance and efficiency in utilization management operations.

Stays current with industry regulations, payer policies, and accreditation standards affecting utilization review.

Serves as a liaison between clinical departments, payers, and leadership to ensure timely resolution of escalated issues.

Performs other duties as assigned.

Education Requirement: High School diploma or equivalent

Experience Requirement: 0-4 years of related/progressive experience as an RN or in Utilization Review

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: Licensed RN

A. Lifting, pushing, and/or pulling objects up to 50lbs:2. Occasional (< 10% of the time)

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:2. Never (< 10% of the time)

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

F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials: 1. Never (< 10% of the time)

G. Repetitive motion:3. Intermittent (100% 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:2. Occasional (< 10% of the time)

L. Loud noises:1. Never

M. Temperature extremes:1. Never

N. Hazardous chemicals and fumes including waste:2. Occasional (< 10% of the time)

O. Radiation:1. Never

P. Burns:1. Never

Q. Cuts/Punctures: 1. Never (< 10% of the time)

R. Bloodborne/airborne pathogens:2. Occasional (< 10% of the time)

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 intermittent 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; and occasional lifting, pushing, or pulling objects weighing up to 50 pounds.

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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.