Utilization Management Representative I – Backoffice Support

Elevance Health•Durham, NC

3d•Remote

About The Position

The Behavioral Health Utilization Management Representative I – Backoffice Support is responsible for processing precertification, prior authorization, and post-service requests for governmental and commercial lines of business. This is primarily a back of office role with no inbound call responsibilities. Limited outbound calls may be required to obtain information or support case resolution. 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. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Requirements

HS diploma or GED
A minimum of 1 year of customer service or call-center experience
Any combination of education and experience which would provide an equivalent background.

Nice To Haves

Administrative support, healthcare operations, data entry, document processing, or back-office experience strongly preferred
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.
Ability to meet established productivity, quality, accuracy, compliance, and turnaround-time expectations preferred
Ability to manage assigned work independently, maintain confidentiality, and follow detailed policies and procedures preferred
Proficiency with computers, electronic work queues, email, and document-management systems preferred
Experience processing faxes, referrals, authorizations, claims, medical records, or healthcare correspondence preferred
Knowledge of HIPAA and healthcare privacy requirements preferred
Experience working in a high-volume, production-based, compliance-focused environment preferred

Responsibilities

Reviews and processes utilization management requests received through fax, electronic queues, and other approved channels.
Accurately enters referral and authorization information into utilization management systems.
Prepares and sends clear, complete, and accurate fax correspondence to providers, facilities, members, and internal partners.
Meets departmental productivity, quality, accuracy, and turnaround-time standards while maintaining a low error rate.
Reviews documentation for completeness and refers cases requiring clinical review to the appropriate clinical reviewer.
Verifies benefits and administrative requirements within the scope of the role.
Documents all actions and correspondence accurately and completely.
Demonstrates accountability and ownership of assigned workload by monitoring queues, prioritizing tasks, following work through completion, and escalating barriers promptly.
Protects confidential information and complies with HIPAA, privacy and security requirements, company policies, accreditation standards, contractual obligations, and applicable federal and state regulations.
Identifies and reports potential quality, privacy, compliance, or regulatory concerns through established escalation processes.
Performs other duties as assigned.