Utilization Management Rep I

About the role

The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy.

Responsibilities

• Manage incoming calls or incoming post services claims work.
• Determine contract and benefit eligibility; provide authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.
• Refers cases requiring clinical review to a Nurse reviewer.
• Identify and enter referral requests into the UM system in accordance with the plan certificate.
• Respond to telephone and written inquiries from clients, providers, and in-house departments.
• Conduct clinical screening process.
• Authorize initial set of sessions to provider.
• Check benefits for facility-based treatment.
• Develop and maintain positive customer relations and coordinate with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Multi-task, handle calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.
• Maintain focus during extended periods of sitting and handle multiple tasks in a fast-paced, high-pressure environment.
• Communicate effectively, both verbally and in writing, with virtual and in-person interactions.
• Show attentiveness to details, critical thinking, and problem-solving abilities.
• Show empathy and persistence to resolve caller issues completely.

Requirements

• High School Diploma or GED.
• Minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences

• Medical terminology training and experience in medical or insurance field preferred.
• Strong oral, written, and interpersonal communication skills.
• Problem-solving skills, facilitation skills, and analytical skills.

Benefits

This role offers a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Pay

Commensurate with experience.

Schedule

Shift: Monday-Friday (Must be willing to work weekends and holidays)