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Urgently Hiring Insurance Utilization Review Jobs in Indiana

AMR ROOFING

Canvasser - Urgently Hiring

Noblesville, IN · On-site

$60K - $270K/yr

American Roof Warriors, a top national leader in the roofing industry, is immediately hiring ... Full Insurance Benefits * 401K with 2% employer match * Company Paid Annual Trip: Punta Canta 2025!

AMR ROOFING

Canvasser - Urgently Hiring

Indianapolis, IN · On-site

$60K - $270K/yr

American Roof Warriors, a top national leader in the roofing industry, is immediately hiring ... Full Insurance Benefits * 401K with 2% employer match * Company Paid Annual Trip: Punta Canta 2025!

AMR ROOFING

Canvasser - Urgently Hiring

Indianapolis, IN · On-site

$60K - $270K/yr

American Roof Warriors, a top national leader in the roofing industry, is immediately hiring ... Full Insurance Benefits * 401K with 2% employer match * Company Paid Annual Trip: Punta Canta 2025!

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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 Manage Nurse (BHS)

Beacon Health System

Granger, IN • On-site

Per diem

Posted 28 days ago

Beacon Health System rating

6.7

Company rating: 6.7 out of 10

Based on 145 frontline employees who took The Breakroom Quiz

534th of 898 rated healthcare providers

Job description

Reports to the Manager. Serves as a liaison between hospitals, physicians, third-party payors and auditors to ensure information needs are met. Responsibilities include the review of medical records to determine the appropriateness and medical necessity of hospitalization. Coordinates and maintains the appeal process for denied hospitalizations. Maintains confidentiality regarding all information collected.
MISSION, VALUES and SERVICE GOALS
  • MISSION: We deliver outstanding care, inspire health, and connect with heart.
  • VALUES: Trust. Respect. Integrity. Compassion.
  • SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Maintains systems for monitoring patient admissions and extended stays for appropriateness and medical necessity by:
  • Reviewing patient admission clinical information using clinical criteria and guidelines available to assist the physician in the determination of medical necessity and/or appropriate admission status (inpatient or outpatient).
  • Communicating, in a timely manner, with third-party payors to justify admission or continued stay.
  • Reviewing extended stays prior to expiration of initially-assigned length of stay.
  • Referring questionable medical necessity or extended stays to the Manager/Director, treating Physician (or Medical Director) as appropriate.
  • Interacting with other Hospital departments in matters related to review decisions and fiscal communications.
  • Facilitating discharge planning by working closely with Nurses and Clinical Social Workers and/or Therapists.
  • These functions apply to associates assigned to Epworth Center only:
  • Maintains system for monitoring and completing Medicare Certification/ Recertification for inpatient psychiatric services.
  • Submission of 1261A forms within 14 days of admission for each Medicaid Psychiatric admission.

Anticipates and reviews denials and facilitates the appeal process by:
  • Anticipating and reviewing denials by payors for lack of medical necessity, inadequate medical information or delay in discharge; also intervening by written appeal to avoid loss of revenue.
  • Arranging physician-to-physician clinical reviews with insurance company, Medical Director and Attending Physician.
  • Writing denial appeal letters on behalf of the patient and/or the Hospital, when appropriate, to avoid loss of revenue.
  • Coordinating with the Manager/Director (and other management as appropriate) to identify and correct weaknesses in the admission and patient care process that can mitigate future denials.
  • Issuing Notices of Non-coverage (insurance &/or Medicare) to patients as necessary.

Serves as a Memorial Hospital and Beacon Health System resource regarding reimbursement by:
  • Maintaining knowledge regarding current regulations (PRO, TJC, AHA, etc.) which impact utilization review activities.
  • Meeting with physicians, Hospital staff, review agencies, insurance companies and others (as relevant) in the assessment of utilization needs.
  • Educating patients and patients' families regarding Medicare regulations and issues, and notices of non-coverage when appropriate.
  • Identifying risk issues concurrently with clinical reviews to provide the Hospital management with valid information on potentially compensable events; also communicating with the Manager/Director and the Director, Risk Management.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:
  • Looking for opportunities to improve departmental operations, patient care delivery and utilization of acute healthcare resources; also striving for continuous quality improvement.
  • Staying current on trends related to medical necessity, DRG and Recovery Audit Contractor (RAC).
  • Completing other job-related assignments and special projects as directed.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
  • Attends and participates in department meetings and is accountable for all information shared.
  • Completes mandatory education, annual competencies and department specific education within established timeframes.
  • Completes annual employee health requirements within established timeframes.
  • Maintains license/certification, registration in good standing throughout fiscal year.
  • Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
  • Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
  • Adheres to regulatory agency requirements, survey process and compliance.
  • Complies with established organization and department policies.
  • Available to work overtime in addition to working additional or other shifts and schedules when required.

Education and Experience
  • The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a Nursing program. A valid and current Registered Nurse license in the state of Indiana is which the associate works is required. Two years of clinical experience is required. Two years of progressively responsible experience in a utilization review environment is preferred.

Knowledge & Skills
  • Requires fundamental knowledge of the revenue cycle process, which includes such things as patient access, utilization review, charge capture, HIM and patient accounting.
  • Requires the advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identify variances in standards of care.
  • Requires knowledge of rules and regulations pertaining to hospital reimbursement.
  • Requires familiarity with managed care principles and an understanding of post-acute continuum of care.
  • Requires the interpersonal skills necessary to maintain effective working relationships and interact effectively with staff, physicians, review agencies, insurance companies, patients and patients' families.
  • Requires the effective communication skills (both verbal and written) necessary to prepare documentation, write appeal letters and to provide education to staff and physicians regarding the revenue cycle process.
  • Demonstrates the ability to be self-motivated, detail oriented and make independent decisions. Also demonstrates the ability to respond quickly and appropriately to customer requests.
  • Demonstrates a working knowledge of the Hospital's computer systems (e.g., Star McKesson, Cerner Power Chart) and proficiency in computer skills (i.e., word processing, spreadsheets, utilizing the internet, etc.).

Working Conditions
  • Works in an office environment and patient care areas when making rounds to review medical records. Will travel between various Beacon facilities.
  • May have contact with patients and family members who may be under considerable stress.
  • May be exposed to bio-hazards.

Physical Demands
  • Requires the physical ability and stamina to perform the essential functions of the position.

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