Utilization Management Rep I (US)

About the Role

This virtual role enables associates to work remotely full-time, except for required in-person training sessions. Candidates must reside within a reasonable commuting distance from an office location or be willing to travel for in-person training. The Utilization Management Representative I coordinates cases for precertification and prior authorization review.

Schedule

Monday–Friday, with occasional weekends and holidays required. Associates 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.

Responsibilities

• Manage incoming calls or post-service 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 enter referral requests into the Utilization Management (UM) system in accordance with the plan certificate.
• Respond to telephone and written inquiries from clients, providers, and in-house departments.
• Conduct clinical screening processes and authorize initial sessions to providers.
• Check benefits for facility-based treatment.
• Develop and maintain positive customer relations, coordinating with various company functions to ensure timely and appropriate handling of customer requests and questions.
• Multi-task across calls, texts, facsimiles, and electronic queues while taking notes and speaking to customers.
• Perform other duties as assigned.

Requirements

• High School diploma or GED.
• Minimum of 1 year of customer service or call-center experience, or an equivalent combination of education and experience.
• 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 for both virtual and in-person interactions.
• Attention to detail, critical thinking, and problem-solving skills.
• Demonstrated empathy and persistence in resolving caller issues.
• Comfort and proficiency with digital tools and platforms to enhance productivity.

Preferred Qualifications

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

Benefits

• Market-competitive total rewards, including merit increases, paid holidays, and Paid Time Off.
• Incentive bonus programs (unless covered by a collective bargaining agreement).
• Medical, dental, vision, short- and long-term disability benefits.
• 401(k) with company match and stock purchase plan.
• Life insurance, wellness programs, and financial education resources.

Work Environment

Elevance Health operates under a Hybrid Workforce Strategy. Associates in this role are primarily virtual but may be required to work at an Elevance Health location at least once per week, with specific expectations discussed during the hiring process.

All new candidates in certain patient/member-facing roles must be vaccinated against COVID-19 and Influenza, unless an acceptable exemption is provided.