Utilization Management Representative I

About the role

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Responsibilities

• Coordinating cases for precertification and prior authorization review.
• Determining contract and benefit eligibility; providing authorization for inpatient admission, outpatient precertification, prior authorization, and post service requests.
• Referring cases requiring clinical review to a Nurse reviewer.
• Identifying and entering referral requests into the UM system in accordance with the plan certificate.
• Responding to telephone and written inquiries from clients, providers, and in-house departments.
• Conducting clinical screening process.
• Authorizing initial set of sessions to provider.
• Checking benefits for facility-based treatment.
• Developing and maintaining positive customer relations and coordinating with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Multitasking, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.
• Handling 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; demonstrating empathy and persistence to resolve caller issues completely.

Qualifications

• Requires HS diploma or GED and a minimum of 1 year of customer service or call-center experience; or any combination of education and experience which would provide an equivalent background.
• Medical terminology training and experience in medical or insurance field preferred.
• Experience with Medicaid waiver programs or other Medicaid utilization management experience preferred.

Benefits

• Affordable Health Insurance, Dental, Vision and Basic Life.
• 401K match, Paid Time Off, Holiday Pay.
• Annual incentive bonus and annual increases plan based on performance.

Pay

Competitive salary commensurate with experience.

Schedule

Monday – Friday, 8 AM - 5 PM EST, possible OT as needed.