Utilization Management Representative I

Elevance Health•Durham, NC

9d•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; provides authorizations for inpatient admissions, outpatient precertification, prior authorization, and post-service requests; and refers cases requiring clinical review to a nurse reviewer. The representative identifies and enters referral requests into the UM system in accordance with plan certificates, conducts clinical screening, authorizes an initial set of sessions to providers, and checks benefits for facility-based treatment. The role responds to telephone and written inquiries from clients, providers, and internal departments, while maintaining positive customer relationships and coordinating timely handling of requests. It requires multitasking across calls, texts, faxes, and electronic queues while taking notes and speaking with customers; sustained focus while seated; and the ability to work in a fast-paced, high-pressure environment. The representative uses digital tools to improve productivity, applies communication, attention-to-detail, critical-thinking, and problem-solving skills, and demonstrates empathy and persistence in resolving caller issues. The position is primarily virtual full-time, with in-person training sessions required. Alternate locations may be considered when the candidate lives within commuting distance of an office, and working from the office may be necessary. The role follows a structured schedule, with occasional overtime or flexibility based on business needs. The anticipated posting end date is November 11, 2026.

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 in virtual and in-person interactions.
Attention to detail, critical-thinking, and problem-solving skills.
Ability to demonstrate empathy and persistence in resolving caller issues.
Ability to multitask in a fast-paced, high-pressure environment and maintain focus during extended periods of sitting.
For URAC-accredited areas: strong oral, written, and interpersonal communication; problem-solving, facilitation, and analytical skills.

Nice To Haves

Medical terminology training.
Experience in a medical or insurance field.

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 promptly.
Handle calls, texts, facsimiles, and electronic queues while simultaneously taking notes and speaking with customers.
Use digital tools and platforms to enhance productivity and minimize manual effort.
Work a structured schedule with occasional overtime or flexibility based on business needs, including the ability to work from the office as necessary.
Perform other duties as assigned.