Utilization Management Representative I

Elevance Health•Meridian, ID

7d•Remote

About The Position

The Utilization Management Representative I coordinates cases for precertification and prior authorization review. The role manages incoming calls or post-service claims work, determines contract and benefit eligibility, and provides authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests. Cases requiring clinical review are referred to a Nurse reviewer. The representative identifies and enters referral requests into the UM system in accordance with the plan certificate, conducts clinical screening, authorizes initial sets of sessions to providers, and checks benefits for facility-based treatment. The representative responds to telephone and written inquiries from clients, providers, and internal departments, develops positive customer relations, and coordinates with company functions to ensure requests and questions are handled appropriately and promptly. The role requires multitasking across calls, texts, facsimiles, and electronic queues while taking notes and speaking with customers, and maintaining focus during extended periods of sitting in a fast-paced, high-pressure environment. Associates use digital tools to improve productivity and minimize manual work, and follow a structured schedule with occasional overtime or flexibility based on business needs, including working from an office when necessary. The position is primarily virtual full-time, with in-person training sessions required; candidates must be within commuting distance of an office unless an accommodation is granted.

Requirements

High school diploma or GED and at least 1 year of customer service or call-center experience, or an equivalent combination of education and experience.
Strong verbal and written communication skills for virtual and in-person interactions.
Attention to detail, critical thinking, and problem-solving skills.
Empathy and persistence in resolving caller issues completely.
Ability to maintain focus during extended periods of sitting and manage multiple tasks in a fast-paced, high-pressure environment.

Nice To Haves

Medical terminology training.
Experience in a medical or insurance field.
For URAC-accredited areas, strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Responsibilities

Manage incoming calls or incoming post-service claims work.
Determine contract and benefit eligibility.
Provide authorization for inpatient admissions, outpatient precertification, prior authorization, and post-service requests.
Refer cases requiring clinical review to a Nurse reviewer.
Identify and enter referral requests into the UM system in accordance with the plan certificate.
Respond to telephone and written inquiries from clients, providers, and in-house departments.
Conduct the clinical screening process.
Authorize the initial set of sessions to providers.
Check benefits for facility-based treatment.
Develop and maintain positive customer relations and coordinate with company functions to handle customer requests and questions appropriately and in a timely manner.
Handle calls, texts, facsimiles, and electronic queues while simultaneously taking notes and speaking to customers.
Use digital tools and platforms to enhance productivity and minimize manual efforts.
Work a structured schedule with occasional overtime or flexibility based on business needs, including working from the office as necessary.
Perform other duties as assigned.