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Utilization Management Clinical Analyst Jobs in Indiana

Powers Health

Physician Advisor

Hobart, IN · On-site

The Physician Advisor will provide clinical expertise to support utilization management (UM) and ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

219 Health Network

Physician Advisor

Hobart, IN · On-site

... Advisor will provide clinical expertise to support utilization management (UM) and quality ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

Powers Health

Physician Advisor

Hobart, IN · On-site

The Physician Advisor will provide clinical expertise to support utilization management (UM) and ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

219 Health Network

Physician Advisor

Munster, IN · On-site

... Advisor will provide clinical expertise to support utilization management (UM) and quality ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

Powers Health

Physician Advisor

Munster, IN · On-site

The Physician Advisor will provide clinical expertise to support utilization management (UM) and ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

Powers Health

Physician Advisor

Munster, IN · On-site

The Physician Advisor will provide clinical expertise to support utilization management (UM) and ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

Powers Health

Physician Advisor

Munster, IN · On-site

The Physician Advisor will provide clinical expertise to support utilization management (UM) and ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

Powers Health

Physician Advisor

Hobart, IN · On-site

The Physician Advisor will provide clinical expertise to support utilization management (UM) and ... Ability to analyze complex clinical and administrative data and provide actionable recommendations.

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All JobsUtilization Management Clinical Analyst JobsUtilization Management Clinical Analyst Jobs in Indiana

Utilization Management Clinical Analyst information

What does a utilization management clinical analyst do?

A Utilization Management Clinical Analyst reviews and analyzes medical records, claims, and treatment plans to ensure that healthcare services provided to patients are medically necessary and cost-effective. They work with healthcare providers, insurance companies, and patients to evaluate the appropriateness of medical care based on established guidelines and policies. Their goal is to optimize patient outcomes while controlling healthcare costs and ensuring compliance with regulatory standards.

What are the key skills and qualifications needed to thrive as a utilization management clinical analyst?

To thrive as a Utilization Management Clinical Analyst, you need a solid background in healthcare, strong analytical abilities, and credentials such as RN or LPN licensure or relevant clinical certifications. Familiarity with utilization management software, electronic health records (EHRs), and claims processing systems is typically required. Excellent communication, critical thinking, and attention to detail are soft skills that help you collaborate effectively and make sound clinical determinations. These competencies are crucial for ensuring the appropriate use of medical resources, maximizing patient outcomes, and maintaining regulatory compliance.

How does a utilization management clinical analyst typically collaborate with clinical and administrative teams to ensure optimal patient care?

A Utilization Management Clinical Analyst works closely with both clinical staff, such as nurses and physicians, and administrative teams to review patient cases and ensure that treatments and services are medically necessary and align with payer guidelines. This role often involves participating in interdisciplinary meetings, communicating findings and recommendations, and helping to develop or refine care protocols. Effective collaboration is essential to balance quality patient care with cost efficiency, and analysts regularly provide feedback and support to improve clinical workflows and documentation.

What is the difference between Utilization Management Clinical Analyst vs Utilization Review Nurse?

AspectUtilization Management Clinical AnalystUtilization Review Nurse
CredentialsHealthcare degree, certifications like CCM or CUCRegistered Nurse (RN), state licensure, certifications like CCM
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, insurance companies, outpatient facilities
Employer & IndustryHealth insurance providers, managed care organizationsHospitals, insurance companies, healthcare facilities
Common Search & ComparisonUtilization Management Clinical Analyst vs Utilization Review Nurse

The main difference between a Utilization Management Clinical Analyst and a Utilization Review Nurse lies in their focus and credentials. Clinical Analysts often have healthcare degrees and certifications like CCM, working primarily in insurance or managed care settings. Utilization Review Nurses are registered nurses with licensure, working in hospitals or outpatient facilities. Both roles involve reviewing medical necessity, but their work environments and professional backgrounds differ.

What are popular job titles related to Utilization Management Clinical Analyst jobs in Indiana?

For Utilization Management Clinical Analyst jobs in Indiana, the most frequently searched job titles are:

What job categories do people searching Utilization Management Clinical Analyst jobs in Indiana look for?

The top searched job categories for Utilization Management Clinical Analyst jobs in Indiana are:

What cities in Indiana are hiring for Utilization Management Clinical Analyst jobs?

Cities in Indiana with the most Utilization Management Clinical Analyst job openings:

Utilization Management Clinical Analyst jobs near you

Utilization Management Nurse

SIHO Insurance Services

Columbus, IN

Full-time

Re-posted 7 hours ago

Job description

Job Title:  Utilization Management Nurse
Reports To: Manager of Utilization Management
Employment Type:  Full-Time, Exempt 

Brief Description of Duties:     
This position is reserved for a licensed Registered Nurse who will perform the Utilization Management (UM) services for SIHO (and affiliated business lines’) members. This individual’s primary role is to ensure that health care services are administered with quality, cost effectiveness, and compliance to plan guidelines are maintained. By performing review of services prospectively, retrospectively, and throughout the episode of care, the UM nurse will make coverage determinations influencing how services are allocated to SIHO’s various member populations.  A candidate’s ability to perform quality reviews within strict efficiency standards is required for this position.  Key responsibilities are as follows: 
- Pre-service, concurrent, and post-service review of necessity of health care services utilizing enrollee medical records and established guidelines set by SIHO and/or state and federal (CMS) guidelines
- Interaction with the member, health care provider, and/or other care team members to complete reviews in most time-efficient manner
- Interaction with the SIHO Medical Director as needed to ensure proper medical necessity decisions are made in a timely manner
- Appropriate documentation of the entire review process utilizing the established documentation system and desk procedures to guarantee accurate reporting metrics and data integrity
- Complete case review and elevation to determinations that are rendered within the contractual and regulatory turnaround times established by SIHO and CMS
- Assist to resolve problems and provide guidance to members of the team and cohorts
-Interpret and abide by organizational policies and procedures; review work regularly to ensure that policies and guidelines are appropriately applied
-Act as a clinical resource to the department and other organization members for services pertaining to medical management, utilization review, and medical necessity
- Act and perform within the scope of professional nursing practice; is responsible in supporting and participating in department strategies and efforts focused on quality improvement
- Responsible for the early identification and assessment of members for inclusion in disease management or care management programs
- Assist in the identification and reporting of Potential Quality of Care concerns and Fraud, Waste and Abuse incidents
- Work as an interdisciplinary team member within Medical Management for all lines of business and commercial group plans 

Minimum Skills Requirement: 
- Registered Nurse with current, unrestricted license in primary state of employment (position may require additional licensing in other states as necessary)Previous UM or Health Plan experience highly preferred
- Desire to work in a fast-paced environment with focus on efficiency while maintaining quality
- Self-directed organization and prioritization skills, and independent time management skills required
- Sound clinical background with experience in the clinical field
- Excellent verbal and written communication skills
- Microsoft Office Experience: Outlook, Word, Excel

We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.