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.
• Refer cases requiring clinical review to a Nurse reviewer.
• Identify and data 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.
• Use digital tools and platforms to enhance productivity and minimize manual efforts.

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.

Schedule

Associates in this role will have a structured work schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary.

Pay

Pay is commensurate with experience.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

EEO Statement

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.