Utilization Management Rep I

Elevance Health•Virginia Beach, VA

5d•$16 - $18•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 requests. The representative will also refer cases needing clinical review to a Nurse reviewer, enter referral requests into the UM system, and respond to inquiries from clients and providers. Key aspects of the role include conducting clinical screenings, authorizing initial sessions, checking benefits for facility-based treatment, and maintaining positive customer relations. Associates are expected to multitask effectively in a fast-paced environment, handling calls, texts, faxes, and electronic queues while taking notes and speaking with customers. The role requires proficiency in maintaining focus during extended periods of sitting, handling multiple tasks, and demonstrating strong verbal and written communication skills. Critical thinking, problem-solving, empathy, and persistence are essential for resolving caller issues completely. Comfort and proficiency with digital tools are also important for enhancing productivity. 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. 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.

Nice To Haves

Medical terminology training and experience in medical or insurance field preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have 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.
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.
Associates in this role are expected to have the ability to multi-task, including handling calls, texts, facsimiles, and electronic queues, while simultaneously taking notes and speaking to customers.
Proficient in maintaining focus during extended periods of sitting and 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.
Demonstrates empathy and persistence to resolve caller issues completely.
Comfort and proficiency with digital tools and platforms to enhance productivity and minimize manual efforts.
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.
Performs other duties as assigned.