Utilization Management Reviewer

Beyond Blue

Job Posting Title:
Utilization Management Reviewer

Requisition Number:
R-000002878

Department Name:
Supervisor, Utilization Review

Work Location:
UK Chandler Hospital, Pavilion A

Grade Level:
11

Type of Position:
Regular

Position Time Status:
Full time

Equivalency Link

Shift:
Day (United States of America)

Job Description:
Job Summary

Responsible for performing advanced utilization reviews to ensure appropriate use of health services, compliance with payer requirements, and accuracy of admission status determinations. Provides collaboration with multidisciplinary teams to support patient care coordination, discharge planning, and financial outcomes. Ensures timely certification, documentation, and communication with payers to secure reimbursement and reduce avoidable days. Develops education for providers and staff regarding payer guidelines, medical necessity criteria, and utilization review processes. Coordinates integration of regulatory, payer, and clinical standards to optimize patient outcomes and organizational performance.

Essential Functions

• Conducts admission and continued stay reviews within required timeframes using evidence-based criteria to validate medical necessity.

• Verifies and documents admission status to ensure alignment with payer requirements and regulatory standards.

• Tracks, monitors, and reports avoidable days, escalating cases as needed to reduce financial and operational risk.

• Collaborates with third-party payers by providing clinical information to secure certifications and authorizations.

• Coordinates with physicians, care teams, and ancillary staff to support effective discharge planning and continuity of care.

• Provides education to physicians, staff, patients, and families regarding payer requirements, admission criteria, and post-hospitalization benefits.

• Communicates financial and insurance-related considerations to clinical teams to support patient-centered decision-making.

• Consults with Physician Advisors and leadership to resolve complex utilization review or payer-related issues.

• Maintains accurate and timely documentation in accordance with organizational policies, payer guidelines, and regulatory requirements.

• Performs other duties as assigned.

Education Requirement: Associate degree - ADN

Experience Requirement: 2+ 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.

Working Conditions

A. Lifting, pushing, and/or pulling objects up to 50lbs:1. Never (< 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:1. 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:2. Occasional (< 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:1. Never (< 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

Physical Demands

This position requires sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); and 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.