Utilization Management Rep I

Elevance Health•Cincinnati, PA

1d•Remote

About The Position

The Utilization Management Representative I is responsible for coordinating cases for precertification and prior authorization review. This role involves managing incoming calls and post-services claims, determining contract and benefit eligibility, and providing authorizations for various services. The representative will also refer cases requiring clinical review to a Nurse reviewer, identify and enter referral requests into the UM system, and respond to inquiries from clients, providers, and internal departments. Additionally, the role includes conducting clinical screenings, authorizing initial sets of sessions, checking benefits for facility-based treatment, and developing positive customer relations. Associates in this role must be proficient in multitasking across various communication channels (calls, texts, faxes, electronic queues) while maintaining focus in a fast-paced environment. They need strong verbal and written communication skills, attention to detail, critical thinking, problem-solving abilities, and empathy. Proficiency with digital tools is also expected. Associates will have a structured work schedule with potential for occasional overtime or flexibility, including the ability to work from the office as needed. 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.
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.

Nice To Haves

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.

Responsibilities

Managing 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.
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.
Ability to multi-task, including handling calls, texts, facsimines, and electronic queues, while simultaneously taking notes and speaking to customers.
Maintaining focus during extended periods of sitting and handling multiple tasks in a fast-paced, high-pressure environment.
Performs other duties as assigned.