Utilization Management Representative I (Miami, FL)

Elevance Health•Miami, FL

4d•Remote

About The Position

Utilization Management Representative I Virtual: 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. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Utilization Management Representative I will be responsible for coordinating cases for precertification and prior authorization review.

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.
Bilingual speaking preferred
URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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.