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Urgently Hiring Insurance Utilization Review Jobs in Indiana

Socket.dev

Specialist, Utilization Review

Lafayette, IN · On-site

$55 - $75/hr

... you'll contribute Utilization Review Specialist facilitates clinical reviews on all patient ... UR contacts external case managers/managed care organizations for certification of insurance ...

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Ascension

Registered Nurse Utilization Review

Carmel, IN · On-site +1

$50 - $52/hr

... or hiring process. Our legitimate email communications will always come from an @ascension.org ... Benefits Paid time off (PTO)Various health insurance options & wellness plansRetirement benefits ...

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All JobsUrgently Hiring Insurance Utilization Review JobsUrgently Hiring Insurance Utilization Review Jobs in Indiana

Urgently Hiring Insurance Utilization Review information

What is an insurance utilization review?

An Insurance Utilization Review is a process used by insurance companies and healthcare organizations to evaluate the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities. Professionals in this role review patient records, treatment plans, and coverage policies to determine if the requested healthcare services meet established criteria for payment and care. Their work helps control healthcare costs, ensures quality care, and supports compliance with regulations. They often collaborate with physicians, nurses, and insurance providers to make informed decisions. Typically, strong analytical, communication, and clinical knowledge are required for this job.

What are the key skills and qualifications needed to thrive as an insurance utilization review specialist?

To excel as an Insurance Utilization Review Specialist, you generally need a healthcare background (often as an RN, LPN, or similar credential), strong analytical skills, and in-depth knowledge of medical terminology and insurance guidelines. Familiarity with utilization management software, electronic medical records (EMR), and certifications such as Certified Professional in Utilization Review (CPUR) are typically required. Exceptional attention to detail, critical thinking, and effective communication with both healthcare providers and insurers set top performers apart. These skills ensure accurate coverage determinations, compliance with regulations, and cost-effective patient care management.

What are the main challenges faced by professionals in insurance utilization review, and how can they be addressed?

One of the main challenges in Insurance Utilization Review is balancing the need to ensure appropriate patient care with the necessity of complying with insurance coverage criteria. This often involves interpreting complex medical records and guidelines under tight deadlines, while communicating effectively with healthcare providers and payers. Building strong organizational and communication skills, and staying updated on changing insurance policies and regulations, can help professionals navigate these challenges successfully. Collaboration with clinical teams and ongoing professional development are also key to thriving in this fast-paced environment.

What is the difference between Urgently Hiring Insurance Utilization Review vs Insurance Claims Processor?

AspectUrgently Hiring Insurance Utilization ReviewInsurance Claims Processor
Primary RoleAssess medical necessity and appropriateness of services for insurance coverageReview and process insurance claims for payment and reimbursement
Required CredentialsLicenses or certifications in health insurance or medical review, often with healthcare backgroundKnowledge of insurance policies, claims processing systems, and basic healthcare understanding
Work EnvironmentHealthcare or insurance companies, often in office or remote settingsInsurance companies, healthcare providers, or third-party claims processing centers
Common Search/ComparisonUrgently Hiring Insurance Utilization Review vs Insurance Claims Processor

While both roles involve insurance and healthcare, Insurance Utilization Review focuses on evaluating the necessity of medical services, whereas Insurance Claims Processors handle the processing and payment of claims. Understanding these differences helps job seekers find the right position aligned with their skills and credentials.

How do I get into a Urgently Hiring Insurance Utilization Review?

To pursue a role in insurance utilization review, candidates typically need a background in healthcare, nursing, or health administration, along with knowledge of insurance policies and medical coding. Relevant certifications such as Certified Professional Utilization Review (CPUR) or Certified Case Manager (CCM) can enhance prospects. Strong analytical skills and familiarity with medical records and insurance systems are also important for entry into this field.

Is utilization review a stressful job?

Utilization review is a detail-oriented role that can be stressful due to the need for accuracy, meeting strict deadlines, and handling complex cases. It often requires strong analytical skills, knowledge of insurance policies, and the ability to work under pressure, especially in high-volume environments or with tight turnaround times.

What cities in Indiana are hiring for Urgently Hiring Insurance Utilization Review jobs?

Cities in Indiana with the most Urgently Hiring Insurance Utilization Review job openings:

Urgently Hiring Insurance Utilization Review jobs near you

Utilization Review Specialist

Innovative Hematology, Inc.

Indianapolis, IN • On-site

Full-time

Posted 20 days ago

Job description

About IHTC
At the Innovative Hematology (IHI), we offer a future where people with rare blood disorders flourish. Our experts provide the highest quality comprehensive services and holistic care to patients with bleeding, clotting and other hematologic disorders, and to their families.
What You Will Do
As the Utilization Review Specialist, you will be responsible for managing prior authorizations, medical necessity reviews, and payer-related requirements for specialty medications. This role works collaboratively with prescribers, pharmacists, clinic staff, and payers to facilitate timely access to medications while ensuring compliance with insurance guidelines, regulatory requirements, and organizational policies. The Utilization Review Specialist serves as a key resource in minimizing prescription delays, supporting reimbursement efforts, optimizing patient outcomes, and minimizing claim denials.
The Opportunity
  • Review incoming specialty medication referrals to identify insurance requirements, prior authorization needs, benefit limitations, coverage exclusions, and payer-specific criteria.
  • Conduct utilization review activities to assess medical necessity, appropriateness of therapy, and compliance with payer policies, clinical guidelines, and formulary requirements.
  • Initiate, prepare, submit, and track prior authorization requests for specialty medications through electronic portals, fax submissions, and verbal payer reviews.
  • Gather, analyze, and validate clinical documentation including chart notes, laboratory results, diagnostic testing, treatment history, and provider assessments to support authorization requests.
  • Collaborate with prescribers, nurses, pharmacists, and clinic staff to obtain missing clinical information and ensure complete and accurate submissions.
  • Monitor authorization status and proactively follow up with insurance carriers, pharmacy benefit managers (PBMs), and third-party administrators to expedite approvals and minimize delays in therapy initiation.
  • Review payer-specific coverage criteria and determine documentation requirements for specialty therapies used in the treatment of hemophilia, von Willebrand disease, sickle cell disease, and other rare hematologic and bleeding disorders.
  • Evaluate denials and identify opportunities for appeal by reviewing payer rationale, medical records, and applicable clinical guidelines.
  • Prepare and submit first-level, second-level, and external appeal requests, including letters of medical necessity and supporting clinical documentation.
  • Maintain detailed records of authorization activities, payer communications, approval dates, denial reasons, appeal outcomes, and reauthorization requirements within pharmacy and electronic health record systems.
  • Track authorization expiration dates and proactively initiate renewal activities to ensure uninterrupted patient access to therapy.
  • Coordinate with clinical pharmacists and providers to address step therapy requirements, quantity limitations, formulary alternatives, and non-covered medication issues.
  • Serve as a liaison between providers, nurses, pharmacists, insurance carriers, manufacturer representatives, and pharmacy staff to facilitate timely access to specialty medications and ensure continuity of care.
  • Assist in identifying patients who may benefit from manufacturer copay assistance programs, patient assistance programs, grants, or alternate funding resources.
  • Monitor turnaround time benchmarks and productivity metrics to ensure timely completion of authorization requests and reauthorizations.
  • Communicate authorization determinations, coverage changes, and appeal outcomes to providers, pharmacy staff, and nursing in a timely and professional manner.
  • Participate in payer audits, accreditation reviews, and internal quality assurance initiatives by maintaining accurate and compliant documentation.
  • Ensure compliance with HIPAA, Medicare, Medicaid, commercial payer regulations, URAC and ACHC accreditation standards, organizational policies, and specialty pharmacy best practices.
  • Identify trends related to payer denials, authorization delays, and documentation deficiencies and provide recommendations for process improvement.
  • Analyze reports related to authorization volumes, approval rates, denial rates, appeal success rates, reimbursement outcomes, accounts receivable performance, and financial impact to support departmental and organizational goals.
  • Maintain a high level of customer service while managing sensitive patient information and complex reimbursement issues in a fast-paced specialty pharmacy environment.
  • Monitor pharmacy accounts receivable related to specialty medication claims, authorizations, and reimbursement activities. Investigate outstanding balances, payer underpayments, claim denials, payment variances, and reimbursement delays. Collaborate with billing, revenue cycle, pharmacy, providers, and payer representatives to resolve claim discrepancies, facilitate payment recovery, reduce aged receivables, and optimize reimbursement performance.

Knowledge:
  • Strong knowledge of utilization review, prior authorization, reauthorization, and appeals processes for specialty medications.
  • Strong understanding of specialty pharmacy reimbursement, claims adjudication, denial management, and revenue cycle processes.
  • Knowledge of commercial insurance, Medicare, Medicaid, managed care organizations, pharmacy benefit managers (PBMs), and medical benefit coverage policies.
  • Knowledge of specialty medication authorization, reauthorization, and appeals processes, including medical necessity reviews and payer-specific clinical criteria.
  • Knowledge of medical terminology, pharmaceutical terminology, disease state management, and clinical documentation requirements.
  • Knowledge of denial management processes, appeals strategies, reimbursement methodologies, and revenue cycle principles.
  • Knowledge of electronic health records (EHRs), pharmacy management systems, payer portals, and other healthcare technology platforms used to support utilization review and reimbursement activities.

Skills:
  • Proficiency in reviewing and interpreting clinical documentation, laboratory results, payer policies, and medical necessity criteria.
  • Excellent verbal and written communication skills with the ability to effectively communicate with providers, pharmacists, nurses, payers, patients, and manufacturer representatives.
  • Strong organizational and time management skills with the ability to prioritize multiple assignments and meet deadlines in a fast-paced environment.
  • Demonstrated attention to detail and accuracy in reviewing clinical documentation, authorization submissions, and payer communications.
  • Proficiency in electronic health records (EHR), pharmacy management systems, payer portals, and Microsoft Office applications, including Excel, Word, Outlook, and Teams.

Abilities:
  • Ability to adapt to changing payer requirements, technology platforms, accreditation standards, and healthcare regulations.
  • Ability to analyze coverage determinations, denial rationales, and reimbursement issues and develop effective resolution strategies.
  • Ability to exercise sound judgment and critical thinking when evaluating payer requirements, authorization requests, and reimbursement challenges.
  • Ability to navigate complex commercial, Medicare, Medicaid, and managed care insurance requirements.
  • Ability to work independently while collaborating effectively within a multidisciplinary healthcare team.

Requirements
  • High school diploma or GED
  • 3-5 years of related experience
  • All IHI employees are expected to enable multi-factor authentication via their personal smart phone/smart device in order to access IHI systems as a requirement of the role.

Benefits
IHI is a not-for-profit program based in Indianapolis and offers a competitive salary and benefit package.
IHI is the only ederally designated comprehensive hemophilia program in Indiana, and serves the entire state through services available in Indianapolis and at outreach clinics.
IHI is a leader in hemophilia care, education and clinical research and has a dedicated on-site multidisciplinary staff to ensure availability of a wide range of required services.
IHI participates in national and international clinical research, including new infusion products and therapies, investigation of long-term outcomes, and the impact of associated conditions. The IHTC research program provides patients access to new therapies, and an opportunity to improve care. Our center has more than 70 clinical research projects involving bleeding disorders, sickle cell disease, thrombosis and more.
The Indiana Hemophilia and Thrombosis Center is an Equal Opportunity Employer.

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