Utilization Management Representative I

Elevance Health • Winston-Salem, NC

3d • Remote

About The Position

Utilization Management Representative I Location: 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. Hours: Monday - Friday, an 8-hour shift between the hours of 8:30 am and 6:30 pm EST. 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 is responsible for coordinating cases for precertification and prior authorization review. How will you make an impact: Managing incoming calls or inbound authorization requests received via fax. 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.

Requirements

• Requires HS diploma or GED and a 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

• For 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.
• Strong typing and communication abilities
• Open-minded and adaptable to evolving technologies
• Versatile and able to manage multiple responsibilities
• Background in healthcare with training in medical terminology
• Experience in the medical or insurance field
• Excellent problem-solving, facilitation, and analytical skills

Responsibilities

• Managing incoming calls or inbound authorization requests received via fax.
• 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.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees