Utilization Management Representative I

Elevance Health•Latham, NY

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. This position identifies and enters referral requests into the UM system according to the plan certificate, responds to telephone and written inquiries, conducts clinical screening, authorizes initial sets of sessions to providers, and checks benefits for facility-based treatment. The representative develops positive customer relationships and coordinates with company functions to address requests and questions promptly. The role requires multitasking across calls, texts, facsimiles, and electronic queues while taking notes and speaking with customers. Associates maintain focus during extended periods of sitting and work in a fast-paced, high-pressure environment. The role is described as primarily virtual and full-time, with in-person training sessions required. Associates may need to work from an office as necessary, and occasional overtime or schedule flexibility may be required 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 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 multitask and maintain focus during extended periods of sitting in a fast-paced, high-pressure environment.
Ability to work a structured schedule, with occasional overtime or flexibility based on business needs, and to work from the office as necessary.

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 the initial set of sessions to providers.
Check benefits for facility-based treatment.
Develop and maintain positive customer relations and coordinate with company functions so customer requests and questions are handled appropriately and promptly.
Handle calls, texts, facsimiles, and electronic queues while taking notes and speaking to customers.
Use digital tools and platforms to enhance productivity and minimize manual efforts.
Perform other duties as assigned.