Utilization Review Specialist

Indiana Hemophilia & Thrombosis Center•Indianapolis, IN

About The Position

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.

Requirements

High school diploma or GED
3-5 years of related experience
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.
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.
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.
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.

Responsibilities

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.