Utilization Management Rep I

Location: Virtual. This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an 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

• HS 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.

Benefits

• 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.

Schedule

Associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.