Utilization Management Representative I (Florida)

CareBridge • Miami, FL

79d

About The Position

The Utilization Management Representative I will be responsible for coordinating cases for precertification and prior authorization review. This role enables associates to work virtually full-time, with the exception of 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.

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.
• Customer Service and Prior Authorization experience preferred.

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.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical benefits
• Dental benefits
• Vision benefits
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services
• Education Level: High school or GED
• Number of Employees: 251-500 employees