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Utilization Review SpecialistPascua Yaqui Tribe, AZTucson, Arizona, United States
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Utilization Review Specialist

Pascua Yaqui Tribe, AZ
  • US
    Tucson, Arizona, United States
  • US
    Tucson, Arizona, United States

Über

Salary: Depends on Qualifications Location : Tucson, AZ Job Type: Full-Time Job Number: 2026-00160 Department: MANAGED CARE Division: YOEME HEALTH PLAN Opening Date: 06/01/2026 Closing Date: 6/15/2026 11:59 PM Arizona Job Summary 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. Principle Duties and ResponsibilitiesEvaluate 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.
Required Knowledge, Skills, and AbilitiesKnowledge 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. Skills and Abilities:
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. Education, Certifications and Experience Required High School Diploma or GED, plus one (1) year experience in a related field. OR
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. Special Requirements:
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.
The Pascua Yaqui Tribe provides 22 days of Paid Time Off which increases with years of service and 15 paid Holidays per year. We offer a comprehensive healthcare benefit package that surpasses or rivals the biggest organizations in Tucson. We encourage you to stay healthy by providing an onsite Wellness Center. Additionally, the Tribe offers a 401(k) Plan with a generous match in which you're immediately vested along with a profit sharing plan after one year of employment. Sworn police and and fire employees are eligible to make Pre-Tax and After-Tax contirbutions to the Arizona Public Safety Personnel Retirement Systems ("PSPRS"). 01
Do you have a High School Diploma or GED?
Yes No
02
Do you have a current valid Driver's license?
Yes No
03
Do you currently have a valid Level 1 Arizona Clearance Card, or are you able to obtain one within ninety (90) days of hire? (Please note: failure to maintain a current Level 1 Clearance Card will result in termination.)
Yes No
04
Do you have one year of experience in medical referrals and claims?
Yes No
05
Do you have an Associate's Degree in Medical Office Administration or a Certification in Medical Office Administration?
Yes No
06
Do you have experience dealing with various health care providers and insurance companies, including one (1) year negotiating payments?
Yes No
07
Are you aware that this position will require you to work non-traditional hours, nights, and weekends?
Yes No
Required Question
  • Tucson, Arizona, United States

Sprachkenntnisse

  • English
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