Utilization Management Rep I

Shift: Monday-Friday. This role enables associates to work virtually full-time, except for required in-person training sessions. Alternate locations may be considered if candidates reside within a commuting distance from an office. Per policy, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment unless accommodation is granted as required by law.

About the role

The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review.

Responsibilities

• Manages incoming calls or incoming post-services claims work.
• Determines contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization, and post-service requests.
• Refers cases requiring clinical review to a Nurse reviewer.
• Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
• Responds to telephone and written inquiries from clients, providers, and in-house departments.
• Conducts clinical screening process.
• Authorizes initial set of sessions to provider.
• Checks benefits for facility-based treatment.
• Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Multi-tasks, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.
• Performs other duties as assigned.

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.
• Ability to maintain focus during extended periods of sitting and handle multiple tasks in a fast-paced, high-pressure environment.
• Strong verbal and written communication skills, both with virtual and in-person interactions.
• Attentive to details, critical thinker, and a problem-solver.
• Demonstrates empathy and persistence to resolve caller issues completely.
• Comfort and proficiency with digital tools and platforms to enhance productivity and minimize manual efforts.
• Structured work schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary.

Preferred Qualifications

• Medical terminology training and experience in medical or insurance field.
• For URAC accredited areas: strong oral, written, and interpersonal communication skills; problem-solving skills; facilitation skills; and analytical skills.

Pay

For candidates working in person or virtually in Virginia, the salary range for this specific position is $15.96 to $18.00 per hour. The salary offered is based on a number of legitimate, non-discriminatory factors set by the Company, including geographic location, work experience, education, and skill level.

Benefits

• Comprehensive benefits package (medical, dental, vision, short and long-term disability).
• 401(k) with company match and stock purchase plan.
• Incentive and recognition programs.
• Paid holidays and Paid Time Off (PTO).
• Life insurance, wellness programs, and financial education resources.