utilization payor specialist rn

Date: Dec 16, 2025

Location: Indianapolis, IN, US, 46202

Organization: HHC

Division:Eskenazi Health

Sub-Division: Hospital

Req ID: 24795

Schedule: Full Time

Shift: Days

Salary Range:

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis.

Exempt

The Utilization Payor Specialist, RN is responsible for working behind the scenes to maximize the quality and cost of efficiency of health services. This position coordinates pre-certifications, re-certifications, the denial management and appeals process, and initial and concurrent reviews. Through regular reviews and audits, the Utilization Payor Specialist ensures that patients receive the care needed without burdening the health care system with unnecessary procedures, ineffective treatments or lengthy hospital stays.

• Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process
• Communicates and negotiates with payers to obtain approvals for the appropriate care level
• Serves as a resource on payor requirements for severity and intensity of service determinations for outpatient and acute inpatient admissions
• Provides timely payor feedback to Case Managers and Social Workers; notifies the Case Manager when additional clinical information may be required that is not currently identified within the electronic medical record or bedside documentation to ensure that services will be approved at the acute level of care as required by the payor
• Ensures pre-certification/authorizations for post-acute services, initial, concurrent reviews, authorizations not obtained by Patient Registration/Admitting or the doctor's office and clinics for direct admissions and procedures
• Reviews patient admission for appropriateness and type; refers case to Medical Director/department leadership for review and course of action when case fails to meet admission standards
• Coordinates and facilitates the most accurate and appropriate patient status for care across the continuum
• Actively communicates and documents payor issues and concerns regarding the initial level of care, continued stay, denials and discharge plans to the Medical Director/department leadership as appropriate
• Supports the denial management process and participates in tracking and reporting denials
• Ensures payor and customer satisfaction through effective communication with the Interdisciplinary Team
• Obtains payor certification for unplanned admissions, homecare and post-acute services as required
• Initiates contact with payers for continued stay; reviews utilizing clinical information; pursues additional information as needed
• Utilizes conflict resolution, critical thinking, and negotiation skills as necessary to ensure timely resolution of issues
• Identifies concurrent third-party payers denials and notifies Case Managers for immediate intervention and escalation to the Medical Director/department leadership
• Coordinates denial and appeals process and responds to all third-party payer denials
• Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation
• Facilitates tracking and