Utilization Review Specialist

The Indiana Hemophilia & Thrombosis Center; Indianapolis (IN); On-site; USD 45,000 - 65,000; Full time

Job summary

The Indiana Hemophilia & Thrombosis Center in Indianapolis is seeking a Utilization Review Specialist to verify patient eligibility with payers and coordinate precertifications and prior authorizations for medications, in collaboration with pharmacy staff and providers.

You will stay up to date on outpatient billing, ensure accurate coding, and communicate denials and required documentation, helping secure timely access to essential therapies.

Qualifications

• Proficiency in clinical/administrative software systems.
• Strong understanding of billing practices and clinic policies.
• Ability to read and interpret medical charts and documentation.

Responsibilities

• Verify patient eligibility with payers and coordinate referrals, precertification, or prior authorizations with pharmacy staff and providers.
• Prepare and submit precertification and prior authorizations to payers; follow up on denials with patients, pharmacies and physicians.
• Notify patients, providers and front office staff before the date of service if approvals are not obtained.
• Maintain compliance with LCD/NCDs and report any medical necessity issues to the team.
• Prepare and submit pharmacy claims to third-party carriers; verify coverage prior to services.
• Follow up on unpaid claims or balances with payers; document steps taken in billing systems.
• Research payer regulations and claim guidelines to ensure compliant submission.

Skills

Clinical software proficiency

Education

High school diploma or GED

Job description

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 verifying patient eligibility with payers and works in conjunction with the pharmacy staff and providers to coordinate referrals, precertification, or prior authorizations for medications.

The Opportunity

• Secure appropriate medical documentation requested by third-party insurance providers.
• Verify insurance coverage for pharmacy benefits.
• Prior to expected date of service, prepare and submit precertification and prior authorizations to payers. Follow up with patients, insurance companies, pharmacy staff, and physicians regarding denials, as well as working with providers and staff to resubmit paperwork to obtain a determination.
• Notify patients, providers and front office staff prior to date of service if referrals, precertification, or prior authorizations are not approved.
• Remain up to date on outpatient billing and benefit changes for third-party insurance carriers. Maintain compliance with all government and non-government insurance company policies and procedures as they relate to outpatient services.
• Ensure correct reporting of patient diagnosis and procedure coding.
• Ensure compliance with LCD/NCDs. Communicate issues with medical necessity or other findings to providers/fellow team members, and utilization review supervisor as needed.
• Prepare and submit pharmacy claims to third party insurance carriers.
• Secure appropriate medical documentation as required by third party insurance carriers.
• Follow up with third party insurance carriers on unpaid claims or balances.
• Research payer regulations and claim guidelines on payment and claim submission criteria to ensure compliant billing practices by utilizing website and associated tools established for payers as applicable.
• Verify insurance coverage for pharmacy services prior to services being rendered.
• Ensure accurate and through documentation of steps taken to resolve prior authorization and claim issues are recorded in billing software(s).
• Monitor claims for accuracy and authorization. Communicate claim issues to team lead and/or utilization review supervisor on a regular basis.
• Work with team lead/utilization review supervisor to establish goals and communicate associated progress as needed.

Knowledge:

• Billing practices, clinic policies, and operating procedures.
• Coding and clinic operating policies.

Skills:

• Proficient in clinical and administrative software systems.

Abilities:

• Understand and interpret policies and regulations.
• Read and interpret medical charts.
• Review documents for accuracy and completeness.
• Communicate effectively and collaborate with staff and providers.

Requirements

• High school diploma or GED
• Minimum1 year related experience

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.