Utilization Management Representative I

Elevance Health•Durham, NC

2d•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. The representative identifies and enters referral requests into the utilization management system in accordance with the plan certificate, conducts clinical screening, refers cases requiring clinical review to a Nurse reviewer, authorizes initial sessions to providers, and checks benefits for facility-based treatment. The position responds to telephone and written inquiries from clients, providers, and internal departments, and coordinates with company functions to handle customer requests and questions in a timely manner. Associates must be able to manage calls, texts, faxes, and electronic queues while taking notes and speaking with customers. The role calls for focus during extended periods of sitting, detail orientation, critical thinking, problem-solving, empathy, persistence, strong communication, and proficiency with digital tools. Other duties may be assigned. The role is described as virtually full-time, with required in-person training and possible office work as needed. Training hours are 7:00 AM–3:30 PM Mountain Time; standard shift hours are 8:30 AM–5:30 PM Mountain Time. Candidates must work rotating weekends and select holidays and be flexible and available for overtime; weekend hours may vary. The work schedule may include occasional overtime or flexibility based on business needs.

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, including virtual and in-person interactions.
Ability to multitask and maintain focus during extended periods of sitting in a fast-paced, high-pressure environment.
Attention to detail, critical-thinking and problem-solving skills, empathy, and persistence in resolving caller issues.
Comfort and proficiency with digital tools and platforms.
Availability to work rotating weekends, select holidays, and overtime; flexibility based on business needs.

Nice To Haves

Inbound call-center experience is strongly preferred.
Medical terminology training and experience in the medical or insurance field are strongly preferred.
For URAC-accredited areas: strong oral, written, and interpersonal communication, problem-solving, facilitation, and analytical skills.

Responsibilities

Coordinate cases for precertification and prior authorization review.
Manage incoming calls or incoming post-service claims work.
Determine contract and benefit eligibility and 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 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.
Handle calls, texts, facsimiles, and electronic queues while taking notes and speaking with customers.
Perform other duties as assigned.