Utilization Management Representative I

Elevance Health•St. Louis, MO

9d•$17 - $28•Remote

About The Position

The Utilization Management Representative I coordinates cases for precertification and prior authorization review. The role manages incoming calls and 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 enters referral requests into the UM system in accordance with the plan certificate, responds to inquiries from clients, providers, and internal departments, conducts clinical screening, authorizes an initial set of sessions to providers, and checks benefits for facility-based treatment. This virtual role is full-time, with in-person training sessions required. Alternate locations may be considered for candidates within commuting distance of an office; candidates outside a reasonable commuting distance from the applicable posting locations generally will not be considered unless legally required accommodation applies. The position requires working a structured schedule, with occasional overtime or flexibility based on business needs and the ability to work from an office when necessary. It is a first-shift, non-management, non-exempt position.

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.
Ability to handle multiple tasks in a fast-paced, high-pressure environment and maintain focus during extended periods of sitting.

Nice To Haves

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

Responsibilities

Manage incoming calls or incoming post-service claims work.
Determine contract and benefit eligibility.
Provide authorization for inpatient admission, 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 an 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.
Multi-task across calls, texts, facsimiles, and electronic queues while taking notes and speaking to customers.
Maintain focus during extended periods of sitting and manage multiple tasks in a fast-paced, high-pressure environment.
Use strong verbal and written communication in virtual and in-person interactions.
Apply attention to detail, critical thinking, and problem-solving skills to resolve issues.
Demonstrate empathy and persistence to resolve caller issues completely.
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.