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Utilization Review Physician Assistant Jobs in Indiana

Ascension

Registered Nurse Utilization Review

Carmel, IN · On-site +1

$50 - $52/hr

Provide case management and/or consultation for complex cases. * Assist departmental staff with ... May prepare statistical analysis and utilization review reports as necessary. * Oversee and ...

Marion Health

Physician Assistant Endocrinology

Marion, IN · On-site

$84K - $114K/yr

The Physician Assistant will accurately document patient interactions in the electronic health record, participate in utilization review processes to ensure patient care and collaborate with ...

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Utilization Review Physician Assistant information

What is a utilization review physician assistant?

A Utilization Review Physician Assistant (PA) is a healthcare professional who evaluates medical records and treatment plans to ensure that patient care is medically necessary, appropriate, and cost-effective. They review cases to determine if the care provided meets established guidelines and insurance requirements. Utilization Review PAs collaborate with physicians, nurses, insurance companies, and other healthcare providers to promote quality care while managing healthcare resources efficiently. Their work typically involves less direct patient care and more administrative responsibilities compared to traditional clinical PA roles.

What are the key skills and qualifications needed to thrive as a utilization review physician assistant?

To thrive as a Utilization Review Physician Assistant, you need a strong clinical background, current PA licensure, and in-depth knowledge of medical guidelines and insurance protocols. Familiarity with electronic medical records (EMRs), utilization management software, and relevant certification such as the Certified Professional in Utilization Review (CPUR) is often beneficial. Strong analytical thinking, attention to detail, and effective communication are crucial soft skills for evaluating cases and interacting with healthcare providers and payers. These competencies are essential to ensure appropriate care delivery, compliance with regulations, and cost-effective use of medical resources.

What are some of the main challenges utilization review physician assistants face when transitioning from direct patient care to a review-focused role?

One of the main challenges Utilization Review Physician Assistants encounter is adapting to a predominantly administrative and analytical environment, as opposed to the hands-on patient care they may be accustomed to. The role requires interpreting clinical documentation, applying payer criteria, and making objective determinations about medical necessity, often with limited patient interaction. Additionally, there can be pressure to meet productivity targets and deadlines while maintaining accuracy and fairness in reviews. Collaboration with physicians, case managers, and insurance representatives is frequent, requiring strong communication and negotiation skills.

What is the difference between Utilization Review Physician Assistant vs Utilization Review Nurse Practitioner?

AspectUtilization Review Physician AssistantUtilization Review Nurse Practitioner
CredentialsMaster's degree, Physician Assistant (PA) license, certification (e.g., NCCPA)Master's or higher degree, Nurse Practitioner (NP) license, certification (e.g., ANCC, AANP)
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, clinics, insurance companies
Employer & Industry UsageCommonly employed in healthcare and insurance sectors for review rolesSimilar usage, often in outpatient and insurance settings

Both roles involve reviewing medical necessity and appropriateness of care, but the Physician Assistant typically has a medical model training background, while the Nurse Practitioner has a nursing model. Both are vital in utilization review, with overlapping responsibilities and work environments.

Can physician assistants do utilization review?

Yes, physician assistants can perform utilization review tasks, which involve evaluating the necessity, appropriateness, and efficiency of healthcare services. They often work in collaboration with physicians and may require certification or training in utilization review processes, depending on the healthcare setting and state regulations.

What are popular job titles related to Utilization Review Physician Assistant jobs in Indiana?

For Utilization Review Physician Assistant jobs in Indiana, the most frequently searched job titles are:

What job categories do people searching Utilization Review Physician Assistant jobs in Indiana look for?

The top searched job categories for Utilization Review Physician Assistant jobs in Indiana are:

What cities in Indiana are hiring for Utilization Review Physician Assistant jobs?

Cities in Indiana with the most Utilization Review Physician Assistant job openings:

Utilization Review Physician Assistant jobs near you
Infographic showing various Utilization Review Physician Assistant job openings in Indiana as of August 2026, with employment types broken down into 64% Full Time, 27% Part Time, and 9% Contract. Highlights an 100% In-person job distribution.

Utilization Review Specialist

Innovative Hematology, Inc.

Indianapolis, IN • On-site

Full-time

Posted 18 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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